Jacob Chandy: Pioneering Neurosurgeon of India 

JACOB CHANDY, WHO passed away in 2007 at the age of 97, was born into a deeply religious Christian family in Kerala, South India. After obtaining his medical education at the Madras Medical College, Madras, he serendipitously came to work with Dr Paul Harrison, a renowned medical missionary, in the Gulf state of Bahrain. Harrison urged Chandy to pursue training in the fledgling specialty of neurosurgery in North America. Chandy received his neurosurgical training at the Montreal Neurological Institute with Wilder Penfield and in Chicago with Theodore Rasmussen. At Harrison's urging, Chandy decided to return to India after completing his training to work at the Christian Medical College in Vellore,. Thus, it was in 1949 that Chandy established the first neurosurgery department in south Asia in Vellore. He initiated the first neurosurgical training program in India at the Christian Medical College in 1957, with a distinct North American neurosurgical tradition. He went on to train nearly 20 neurosurgeons, many of whom set up new departments of neurosurgery in their home states. Chandy also had several other remarkable achievements to his credit. Despite the pressures of clinical practice, he insisted on fostering both basic and clinical neurosciences within his department, an arrangement that persists to this day in the Department of Neurological Sciences at the Christian Medical College, Vellore. As the Principal (Dean) of the Christian Medical College, Chandy displayed his skills as a medical educator and administrator. In this role, he was instrumental in starting specialty training programs in several other medical and surgical disciplines. His greatest legacies survive in the form of the department that he founded and his trainees and their students who have helped to establish neurosurgery all over the country. Copyright (C) by the Congress of Neurological Surgeons

Natural History of Supratentorial Hemangioblastomas in von Hippel-Lindau Disease 

BACKGROUND: Supratentorial hemangioblastomas are rare lesions, occurring either sporadically or in von Hippel-Lindau disease. OBJECTIVE: Following recent advances in our understanding of the natural history of von Hippel-Lindau-associated cerebellar and spinal hemangioblastomas, we conducted a study of the natural history of supratentorial hemangioblastomas in von Hippel-Lindau disease. METHODS: We reviewed a series of 18 supratentorial hemangioblastomas in 13 patients with von Hippel-Lindau disease. Clinical, genetic, and serial imaging data and operative records were analyzed. RESULTS: Hemangioblastomas were most commonly seen in the temporal lobe. Only 6 tumors had a cyst at diagnosis or during follow-up, and only 6 patients had associated symptoms at presentation or during follow-up. The most frequent clinical presentations were intracranial hypertension and visual loss. Of 14 tumors with documented serial imaging, 13 demonstrated tumor growth. Rates and patterns of tumor growth were unique to each patient. The mechanism of cyst formation described in other locations was also demonstrated in the supratentorial region. Patterns of peritumoral edema and rate of cyst formation seemed to be influenced by the presence of anatomic barriers. Germline VHL mutation was identified in all patients, but no specific genotype-phenotype correlation was found, although a familial predisposition is suggested. CONCLUSION: This series illustrates the wide variation in tumor locations, patterns of growth, and edema progression seen in supratentorial hemangioblastomas and adds to our knowledge of the natural history of hemangioblastomas. Copyright (C) by the Congress of Neurological Surgeons

Endoscopic Third Ventriculostomy Vs Cerebrospinal Fluid Shunt in the Treatment of Hydrocephalus in Children: A Propensity Score-Adjusted Analysis 

BACKGROUND: Endoscopic third ventriculostomy (ETV) has preferentially been offered to patients with more favorable prognostic features compared with shunt. OBJECTIVE: To use advanced statistical methods to adjust for treatment selection bias to determine whether ETV survival is superior to shunt survival once the bias of patient-related prognostic factors is removed. METHODS: An international cohort of children (<= 19 years of age) with newly diagnosed hydrocephalus treated with ETV (n = 489) or shunt (n = 720) was analyzed. We used propensity score adjustment techniques to account for 2 important patient prognostic factors: age and cause of hydrocephalus. Cox regression survival analysis was performed to compare time-to-treatment failure in an unadjusted model and 3 propensity score-adjusted models, each of which would adjust for the imbalance in prognostic factors. RESULTS: In the unadjusted Cox model, the ETV failure rate was lower than the shunt failure rate from the immediate postoperative phase and became even more favorable with longer duration from surgery. Once patient prognostic factors were corrected for in the 3 adjusted models, however, the early failure rate for ETV was higher than that for shunt. It was only after about 3 months after surgery did the ETV failure rate become lower than the shunt failure rate. CONCLUSIONS: The relative risk of ETV failure is initially higher than that for shunt, but after about 3 months, the relative risk becomes progressively lower for ETV. Therefore, after the early high-risk period of ETV failure, a patient could experience a long-term treatment survival advantage compared with shunt. It might take several years, however, to realize this benefit. Copyright (C) by the Congress of Neurological Surgeons

Patient Perception of Combined Awake Brain Tumor Surgery and Intraoperative 1.5-T Magnetic Resonance Imaging: The Kiel Experience 

OBJECTIVE: To assess patients' perspective of combined awake craniotomy and intraoperative magnetic resonance imaging (MRI) in a prospective study. METHODS: We evaluated 25 consecutive patients prospectively. Qualitative and quantitative results were obtained by a psychologist via a structured interview 5 +/- 2 days postoperatively, supplemented by preoperative and postoperative assessment of the patients' mood with the Hospital Anxiety and Depression Scale, as well as parts of a structured clinical interview during the postoperative assessment. RESULTS: Satisfaction with the experience was high in almost all cases. Only 1 patient recalled experiencing considerable discomfort during the operation. About one-third (39%) of our sample described minor to moderate difficulties; the remaining were entirely satisfied. CONCLUSION: Although the combination of awake craniotomy and intraoperative MRI is demanding, it was both tolerable and reasonable for the patients. Our data confirm that intraoperative MRI appears to have no additional significant impact on the subjective patient perception, although it does prolong the procedure. Copyright (C) by the Congress of Neurological Surgeons

The Impact of Tinnitus and Vertigo on Patient-Perceived Quality of Life After Cerebellopontine Angle Surgery 

BACKGROUND: Quality of life (QOL) has come into focus after treatment for cerebellopontine angle (CPA) lesions. OBJECTIVE: This study compared subjective (tinnitus, vertigo) and objective (hearing loss, facial palsy) results of CPA surgery with patient-perceived impairment of QOL. METHODS: A retrospective analysis of a consecutive series of 48 patients operated on for either a vestibular schwannoma or a meningioma in the CPA was performed. Patient's subjective impairment of QOL by tinnitus, vertigo, hearing loss, and facial nerve palsy was assessed by a visual analog scale (VAS). Objective facial nerve and hearing function were determined using House-Brackmann and Gardner-Robertson classification systems, respectively. RESULTS: The return rate of questionnaires was 64.4%, with mean follow-up time of 417.2 (+/- 46.4) days. Mean preoperative tinnitus score was 2.5 (+/- 0.5) and increased to 4.6 (+/- 0.7) postoperatively (P < .01). The vertigo score increased from 2.0 (+/- 0.3) to 5.8 (+/- 0.6) (P < .001). Pre- and postoperative values for hearing loss were 3.4 (+/- 0.6) and 5.9 (+/- 0.7), respectively (P < .01), and for facial nerve palsy 0.7 (+/- 0.4) compared with 3.1 (+/- 0.6) postoperatively (P < .01). House-Brackmann grade 1 or 2 was determined in 87.1% of patients before and in 80.6% after surgery. Serviceable hearing (Gardner-Robertson classes I-III) was found in 75% before and in 64.3% after surgery. CONCLUSION: Preservation of facial nerve and hearing function are not the only important criteria defining QOL after CPA surgery. Tinnitus and vertigo may have a significant underestimated impact on the patient's postoperative course and QOL. Copyright (C) by the Congress of Neurological Surgeons

Gamma Knife Surgery for Cavernous Hemangiomas in the Cavernous Sinus 

BACKGROUND: Cavernous hemangioma in the cavernous sinus (CS) is a rare vascular tumor. Direct microsurgical approach usually results in massive hemorrhage. Radiosurgery has emerged as a treatment alternative to microsurgery. OBJECTIVE: To further investigate the role of Gamma Knife surgery (GKS) in treating CS hemangiomas. METHODS: This was a retrospective analysis of 7 patients with CS hemangiomas treated by GKS between 1993 and 2008. Data from 84 CS meningiomas treated during the same period were also analyzed for comparison. The patients underwent follow-up magnetic resonance imaging at 6-month intervals. Data on clinical and imaging changes after radiosurgery were analyzed. RESULTS: Six months after GKS, magnetic resonance imaging revealed an average of 72% tumor volume reduction (range, 56%-83%). After 1 year, tumor volume decreased 80% (range, 69%-90%) compared with the pre-GKS volume. Three patients had > 5 years of follow-up, which showed the tumor volume further decreased by 90% of the original size. The average tumor volume reduction was 82%. In contrast, tumor volume reduction of the 84 cavernous sinus meningiomas after GKS was only 29% (P < .001 by Mann-Whitney U test). Before treatment, 6 patients had various degrees of ophthalmoplegia. After GKS, 5 improved markedly within 6 months. Two patients who suffered from poor vision improved after radiosurgery. CONCLUSION: GKS is an effective and safe treatment modality for CS hemangiomas with long-term treatment effect. Considering the high risks involved in microsurgery, GKS may serve as the primary treatment choice for CS hemangiomas. Copyright (C) by the Congress of Neurological Surgeons

Hormone Receptor Expression in Craniopharyngiomas: A Clinicopathological Correlation 

BACKGROUND: Extensive neurosurgical resection of craniopharyngiomas often requires lifetime hormonal substitution. OBJECTIVE: We investigated the effect of the hormone receptor expression of insulinlike growth factor-1, growth hormone-releasing hormone receptor, growth hormone, progesterone, estrogen (ER-1, ER-[beta]), and leptins (Ra6.4, Ra12.1, Rb) on tumor recurrence, size, and proliferation using clinical, histopathological, and molecular genetic analysis. PATIENTS AND METHODS: cDNA expression analysis was obtained in a cohort of 20 patients suffering from a craniopharyngioma to systematically determine the expression of above-mentioned receptors. In addition, 51 tumor samples were available to immunohistochemically investigate the extent and distribution of estrogen and progesterone receptors. In 18 tumor specimens, both experimental paradigms could be performed. RESULTS: All hormone receptors under study, including leptins, were detectable in craniopharyngiomas with reverse-transcription polymerase chain reaction but did not reach significance regarding the tested parameters. However, a correlation was observed between tumor size and cell proliferation indexes, as well as with cDNA expression levels of ER-1 and growth hormone receptors. CONCLUSION: The present preliminary data point to a correlation between estrogen and growth hormone receptor expression and proliferation indexes with tumor size in craniopharyngiomas. Because of the small cohort of tumors, these data require expansion and validation. This is the first report about leptin expression in this tumor entity. These findings should prompt careful consideration of hormonal replacement therapy regimens in patients with tumor remnants and evidence of respective receptor expression. Copyright (C) by the Congress of Neurological Surgeons

Bilateral Subthalamic Deep Brain Stimulation in Parkinson Disease Patients With Severe Tremor 

BACKGROUND: Previous studies have shown that subthalamic nucleus (STN) deep brain stimulation (DBS) improves tremor in Parkinson disease (PD). However, the patients included in those studies were unselected for tremor severity. OBJECTIVE: We specifically assessed the effect of STN DBS on tremor in selected PD patients with severe tremor. METHODS: Seventy-two PD patients who had received bilateral STN DBS were included. The effects of STN DBS on the off-medication tremor, the on-medication tremor, and the off-medication action tremor in patients selected as the worst one-third in each category at baseline were evaluated after a mean duration of > 2 years. RESULTS: In patients with severe off-medication tremor, off-medication tremor score improved from 12.28 +/- 2.80 at baseline to 1.93 +/- 2.85 at the last follow-up (P < .001). The off-medication tremor in the off-stimulation state at the last follow-up was less severe than the preoperative off-medication tremor. In patients with severe on-medication tremor, on-medication tremor score improved from 6.17 +/- 2.45 to 1.35 +/- 2.58 (P < .001). In patients with severe off-medication action tremor, off-medication action tremor score improved from 5.08 +/- 1.35 to 1.24 +/- 1.42 (P < .001). CONCLUSION: STN DBS is effective for severe off- and on-medication tremor and off-medication action tremor in PD. Our findings suggest that STN DBS reduces PD tremor through, at least in part, its effect on the tremor-generating mechanism independent of dopaminergic transmission and that long-term electrical stimulation of STN might induce a structural or neurochemical change leading to the improvement of tremor. Copyright (C) by the Congress of Neurological Surgeons

Prospective Comparison of Posterior Fossa Exploration and Stereotactic Radiosurgery Dorsal Root Entry Zone Target as Primary Surgery for Patients With Idiopathic Trigeminal Neuralgia 

BACKGROUND: Trigeminal neuralgia (TN) is the most common facial pain syndrome, with an incidence of approximately 27 per 100 000 patient-years. OBJECTIVE: To prospectively compare facial pain outcomes for patients having either a posterior fossa exploration (PFE) or stereotactic radiosurgery (SRS) as their first surgery for idiopathic TN. METHODS: Prospective cohort study of 140 patients with idiopathic TN who had either PFE (n = 91) or SRS (n = 49) from June 2001 until September 2007. The groups were similar with regard to sex, pain location, and pain duration. Patients who had SRS were older (67.1 vs 58.2 years; P < .001). The median follow-up after surgery was 38 months. RESULTS: Patients who had PFE more commonly were pain free off medications (84% at 1 year, 77% at 4 years) compared with the SRS patients (66% at 1 year, 56% at 4 years; hazard ratio = 2.5; 95% confidence interval, 1.4-4.6; P = .003). Additional surgery for persistent or recurrent face pain was performed in 14 patients after PFE (15%) compared with 17 patients after SRS (35%; P = .009). Nonbothersome facial numbness occurred more frequently in the SRS group (33% vs 18%; P = .04). No difference was noted in other complications between patients who had PFE (12%) (dysesthetic facial pain, n = 3; cerebrospinal fluid leakage, n = 3; hearing loss, n = 2; wound infection, n = 1; pneumonia, n = 1; deep vein thrombosis, n = 1) and patients who had SRS (8%) (dysesthetic facial pain, n = 4; P = .47). CONCLUSION: PFE is more effective than SRS as a primary surgical option for patients with idiopathic TN. Copyright (C) by the Congress of Neurological Surgeons

Critical Assessment of Operative Approaches for Hearing Preservation in Small Acoustic Neuroma Surgery: Retrosigmoid Vs Middle Fossa Approach 

BACKGROUND: For hearing preservation in acoustic neuroma (AN) surgery, the middle fossa (MF) or retrosigmoid (RS) approach can be used. Recent literature advocates the use of the MF approach, especially for small ANs. OBJECTIVE: To present our critical analysis of operative results comparing these 2 approaches. METHODS: We reviewed 504 consecutive AN resections performed between November 1998 and September 2007 and identified 43 MF and 82 RS approaches for tumors smaller than 1.5 cm during hearing preservation surgery. Individual cases were examined postoperatively with respect to hearing ability, facial nerve activity, operative time, blood loss, and symptoms resulting from retraction of the cerebellar or temporal lobes. RESULTS: Good hearing function (American Academy of Otolaryngology-Head and Neck Surgery class B or better) was preserved in 76.7% of patients undergoing surgery via the MF approach and in 73.2% of the RS group (P = .9024). Temporary facial nerve weakness was more frequent in the MF group (P = .0249). However, late (8-12 months) follow-up examinations showed good recovery in both groups. The mean operative time was 7.45 hours for the MF group and 5.2 hours for the RS group (P = .0318). The mean blood loss was 280.5 mL for the MF group and 80.8 mL for the RS group (P < .0001). Temporary symptoms of temporal lobe edema (drowsiness or speech disturbance) were noted in 6 MF cases. No cerebellar dysfunction was noted in the RS group. CONCLUSIONS: Although hearing and facial nerve function assessed at approximately 1 year was similar with these 2 approaches, the RS approach provided several advantages over the MF approach for ANs smaller than 1.5 cm. Copyright (C) by the Congress of Neurological Surgeons

Deep Brain Stimulation of the Ventral Intermediate Nucleus of the Thalamus for Tremor in Patients With Multiple Sclerosis 

BACKGROUND: Tremor is an important cause of disability in patients with multiple sclerosis (MS). Deep brain stimulation (DBS) in the ventral intermediate nucleus (VIM) of the thalamus is said to be beneficial for MS tremor. OBJECTIVE: To assess the long-term efficacy of VIM DBS for MS disabling tumor. METHODS: We treated 10 patients (4 men and 6 women) with advanced MS-related medication-resistant tremor with DBS at the VIM thalamic nucleus. DBS was unilateral in 9 patients and bilateral in 1 patient in 2 stages. Contralateral arm tremor was assessed with the Fahn-Tolosa-Marin tremor rating scale. RESULTS: At 1 year, 5 of 10 patients (5 of 11 hemispheres) had a reduction in tremor scores with stimulation compared with baseline; in 3 patients, the reduction was > 50%. After 36 months, 3 patients continued benefiting from stimulation, 2 having > 50% improvement. Of the 6 symptomatic sides that did not benefit at 1 year, 3 failed to have even initial benefit, and 3 had a transient improvement lasting < 1 year. One patient stopped using stimulation because of a lack of improvement at 5 months after surgery and was lost to follow-up. CONCLUSION: Approximately one-half of the patients derived some benefit from VIM DBS 1 year after surgery, but this benefit reached a > 50% reduction in only 30% of the patients. This level of improvement may be related to the variability of the demyelinating lesions and the superimposition of ataxia in the MS patients. Developing better treatments for MS tremor continues to be a challenge. Copyright (C) by the Congress of Neurological Surgeons

Thoracoscopic Sympathectomy for Hyperhidrosis: Analysis of 642 Procedures With Special Attention to Horner's Syndrome and Compensatory Hyperhidrosis 

BACKGROUND: Hyperhidrosis (HH) profoundly affects a patient's well-being. OBJECTIVE: We report indications and outcomes of 322 patients treated for HH via thoracoscopic sympathectomy or sympathotomy at the Barrow Neurological Institute. METHODS: A prospectively maintained database of all patients who underwent sympathectomy or sympathotomy between 1996 and 2008 was examined. Additional follow-up was obtained in clinic, by phone, or by written questionnaire. RESULTS: A total of 322 patients (218 female patients) had thoracoscopic treatment (mean age 27.6 years; range, 10-60 years). Mean follow-up was 8 months. Presentations included HH of the palms (43 patients, 13.4%), axillae (13 patients, 4.0%), craniofacial region (4 patients, 1.2%), or some combination (262 patients, 81.4%). Sympathectomy and sympathotomy were equally effective in relieving HH. Palmar HH resolved in 99.7% of patients. Axillary or craniofacial HH resolved or improved in 89.1% and 100% of cases, respectively. Hospital stay averaged 0.5 days. Ablating the sympathetic chain at T5 increased the incidence of severe compensatory sweating (P = .0078). Sympathectomy was associated with a significantly higher incidence of Horner's syndrome compared with sympathotomy (5% vs 0.9%, P = .0319). Patients reported satisfaction and willingness to undergo the procedure again in 98.1% of cases. CONCLUSION: Thoracoscopic sympathectomy is effective and safe treatment for severe palmar, axillary, and craniofacial HH. Ablating the T5 ganglion tends to increase the severity of compensatory sweating. Sympathectomy led to a higher incidence of ipsilateral Horner's syndrome compared with sympathotomy. Copyright (C) by the Congress of Neurological Surgeons

Indocyanine Green Videoangiography in the Management of Dural Arteriovenous Fistulae 

OBJECTIVE: To evaluate the usefulness of indocyanine green (ICG) videoangiography in the operative management of dural arteriovenous fistulae (dAVFs). METHODS: Intraoperative ICG videoangiography was used as a surgical adjunct in 25 patients with cranial and spinal dural arteriovenous fistulae to identify the fistula and verify its complete obliteration. The findings on ICG videoangiography were compared with intraoperative and/or postoperative imaging. RESULTS: All dural arteriovenous fistulae were clearly identified by intraoperative ICG videoangiography and obliteration was documented in each case. Findings on ICG videoangiography correlated with intraoperative and/or postoperative imaging. CONCLUSION: ICG videoangiography is a useful adjunct to the surgical management of dural arteriovenous fistulae for localization and confirmation of complete obliteration. The safety and ease of use make it an attractive modality. The surgeon can only evaluate what is visualized under the operating microscope and must therefore fully expose the venous drainage of the fistula to confirm obliteration. Copyright (C) by the Congress of Neurological Surgeons

Outcomes of Microneurovascular Facial Reanimation Using Masseteric Innervation in Patients With Long-Standing Facial Palsy Resulting From Cured Brainstem Lesions 

BACKGROUND: The functions of the human face are not only of esthetic significance but also extend into metaphoric nuances of psychology. The loss of function of one or both facial nerves has a remarkable impact on patients' lives. OBJECTIVE: To retrospectively analyze the functional outcomes of microneurovascular facial reanimation using masseteric innervation. METHODS: Seventeen patients with irreparable facial paralysis resulting from benign lesions involving the facial nuclei (n = 14) or Mobius syndrome (n = 3) were treated with free muscle flaps for oral commissural reanimation using ipsilateral masseteric innervation and using temporalis muscle transfer for eyelid reanimation. Results were analyzed by the absolute commissural excursion and commissural excursion index and by a patient self-evaluation score. Presence of synkinesis was documented. Follow-up ranged from 8 to 48 months (mean, 26.4 months). RESULTS: Normalization of the commissural excursion index was observed in 8 of 17 patients (47%), an improvement was seen in 7 of 17 (41%), and failure was observed in 2 of 17 (12%). The individual dynamics of absolute commissural excursion and commissural excursion index changes are presented. A natural smiling response was observed in 10 of 17 patients (59%) but not in the remaining 7 (41%). This response reflected the patient's ability to relay the natural emotion of smiling through the masseteric nerve. Patients' self-evaluation scores were a level higher than objective indices. CONCLUSIONS: Innervation of free muscle flaps with the masseteric nerve for oral commissure reanimation might play an important role in patients with lesions of the facial nuclei (as in Mobius syndrome). Synkinesis persists for long periods after surgery. However, most of the patients learned to express their emotions by overcoming this phenomenon. Despite hypercorrection or inadequate correction, patients evaluated themselves favorably. Copyright (C) by the Congress of Neurological Surgeons

Decompressive Craniectomy Is Not an Independent Risk Factor for Communicating Hydrocephalus in Patients With Increased Intracranial Pressure 

BACKGROUND: It was recently suggested that communicating hydrocephalus is an almost universal finding after hemicraniectomy and that early cranioplasty may prevent the need for permanent cerebrospinal fluid diversion in these patients. OBJECTIVE: To conduct a study in an attempt to verify these findings. METHODS: The medical records of all patients who underwent decompressive craniectomy for medically refractory elevated intracranial pressure between 2001 and 2009 were retrospectively reviewed. Patients with subarachnoid hemorrhage, intraventricular hemorrhage, or head trauma were excluded. Hydrocephalus was classified as internal or external and as clinically significant or asymptomatic. RESULTS: The patient population consisted of 17 patients, 8 men and 9 women, with a median age of 44 years (range, 27-53 years). Etiologies included malignant middle cerebral artery territory infarction in 12 patients, hemorrhagic transformation of ischemic cerebrovascular accident in 2 patients, dural sinus thrombosis in 2 patients, and hemorrhagic cerebrovascular accident in 1 patient. The extent of craniectomy ranged from a large bone flap in 4 patients to a standard hemicraniectomy in 13 patients. Two patients died and 1 was lost to follow-up during the acute stage. The remaining 14 patients underwent cranioplasty after a median interval of 21 days (range, 3-42 days). In none of these patients did clinically significant hydrocephalus develop requiring cerebrospinal fluid diversion. Asymptomatic extra-axial cerebrospinal fluid collections developed in 2 patients that resolved spontaneously after cranioplasty. CONCLUSION: Our results suggest that, contrary to some beliefs, hydrocephalus does not frequently occur after decompressive craniectomy. Copyright (C) by the Congress of Neurological Surgeons

Longitudinal Prospective Long-term Radiographic Follow-up After Treatment of Single-Level Cervical Disk Disease With the Bryan Cervical Disc 

BACKGROUND: Many short- and intermediate-term radiological and clinical studies on cervical arthroplasty with the Bryan Cervical Disc have been published, providing, most of the time, satisfactory results. OBJECTIVE: To prospectively assess the intermediate and long-term radiographic characteristics of disk replacement surgery with the Bryan Cervical Disc and to correlate these results with clinical outcome. METHODS: Range of motion was measured with a validated tool. Intervertebral disk degeneration was assessed with a quantitative scoring system. Heterotopic ossification was evaluated with a previously published scoring system. Device stability was investigated by measuring subsidence and anteroposterior migration. General clinical patient outcome was assessed with the Odom classification system. RESULTS: Eighty-nine patients were initially included in this prospective long-term study. One patient was reoperated on at the index level and 4 were reoperated on at an adjacent level; those patients were not further analyzed. The mobility at the treated level was preserved in >= 85% of our cases. The insertion of the prosthesis did not lead to an increase in mobility at the adjacent levels. The degeneration score increased at both adjacent levels. Heterotopic ossification was present in 34% to 39% of the patients, depending on the follow-up point. No cases of anteroposterior migration or subsidence were found. More than 82% of all patients had a good to excellent clinical outcome in the long run. CONCLUSION: The device maintains preoperative motion at the index and adjacent levels, seems to protect against acceleration of adjacent-level degeneration as seen after anterior cervical discectomy and fusion, and remains securely anchored in the adjacent bone mass in the long run. Heterotopic ossification was frequently seen. The vast majority of all patients had a good to excellent clinical outcome. Copyright (C) by the Congress of Neurological Surgeons

Utility of the Immediate Postoperative Cortisol Concentrations in Patients With Cushing's Disease 

BACKGROUND: Several investigators have recommended serial measurements of serum cortisol in the days following pituitary surgery to identify patients at risk of recurrence. OBJECTIVE: We systematically reviewed the literature on this topic and analyzed the usefulness of this test in our own patient population. METHODS: We identified studies publishing data regarding recurrence rates after transsphenoidal surgery for Cushing's disease, focusing on studies with data regarding patients with early postoperative cortisol levels. We determined a cumulative relative risk of having a subnormal vs normal cortisol level postoperatively using a fixed-effects meta-analysis model. Additionally, we analyzed our own patients with Cushing's disease undergoing transsphenoidal surgery and performed Kaplan-Meier analysis of recurrence-free survival for patients with undetectable, subnormal but detectable, and normal immediate 8 AM serum cortisol levels. RESULTS: Fourteen studies met inclusion criteria. The length of follow-up varied between 32 and 115 months. The cumulative rate of recurrence in the group of patients with subnormal cortisol levels was 9% (95% confidence interval: 6%-12%). The cumulative rate of recurrence in the group with normal cortisol levels was 24% (95% confidence interval: 17%-31%). We analyzed 73 of our own patients and found similar recurrence rates in patients with subnormal vs normal early postoperative cortisol levels (4% vs 22%, [chi]2 test, P < .05). CONCLUSION: Although a subnormal early postoperative cortisol level is predictive of improved outcome after transsphenoidal surgery for Cushing's disease, it is not analogous with cure, nor is a normal level completely predictive of future failure. Copyright (C) by the Congress of Neurological Surgeons

Less Invasive Surgical Correction of Adult Degenerative Scoliosis, Part I: Technique and Radiographic Results 

BACKGROUND: Adult scoliosis is a condition with increasing prevalence and medical and socioeconomic importance. Surgery is fraught with a significant complication rate in an elderly multimorbid patient population. OBJECTIVE: To assess technical feasibility and radiographic results of image-guided less invasive correction of adult degenerative scoliosis. METHODS: Thirty individuals (age, 64-88 years) with progressive deformity (coronal Cobb angles > 25[degrees] and < 85[degrees]), intractable back pain, radiculopathy, or neurogenic claudication were treated by less invasive decompression and fusion (unilateral transforaminal interbody cage instrumentation and bilateral facet fusions) with recombinant human bone morphogenetic protein-2, spanning 3 to 8 segments (average, 6 segments), using biplanar fluoroscopy or intraoperative computed tomography (iCT)-based navigation. Accuracy of screw placement, curve correction, and fusion rate were evaluated during a mean follow-up of 19.6 months. RESULTS: With 415 screws implanted, misplacement (grade II or greater) was not observed, and no implants required revision. Spinal iCT with automated registration required 17.5 +/- 8.5 minutes (single registration for all segments); monosegmental bilateral screw insertion required 6.8 +/- 3.4 minutes. Mean sagittal (coronal) Cobb angle correction was 44.8 +/- 10.7[degrees] (31.7 +/- 13.7[degrees]). Mean lumbar lordosis increased from 8.8 +/- 8.9[degrees] to -36 +/- 6.9[degrees], and sagittal balance was reduced from 31.6 +/- 15.2 to 8 +/- 8.4 mm. Solid fusion was confirmed in 90% of instrumented segments at 16 months. Average radiation dose to the surgeon was 0.025 mSv for single-level transforaminal lumbar interbody fusion with fluoroscopic guidance vs 0 mSv with iCT navigation. CONCLUSION: Instrumented correction of adult deformity was significantly facilitated by iCT navigation, eliminating radiation exposure to the surgeon. Intraoperative biplanar CT scout views including pelvis and shoulders allow comprehensive assessment of multiplanar deformity correction. Fusion rates obtained with less invasive access equal those of conventional open technique. Copyright (C) by the Congress of Neurological Surgeons

Isolation and Perivascular Localization of Mesenchymal Stem Cells From Mouse Brain 

BACKGROUND: Although originally isolated from the bone marrow, mesenchymal stem cells (MSCs) have recently been detected in other tissues. However, little is known about MSCs in the brain. OBJECTIVE: To determine the extent to which cells with the features of MSCs exist in normal brain tissue and to determine the location of these cells in the brain. METHODS: Single-cell suspensions from mouse brains were cultured according to the same methods used for culturing bone marrow-derived MSCs (BM-MSCs). These brain-derived cells were analyzed by fluorescence-activated cell sorting for surface markers associated with BM-MSCs (stem cell antigen 1 [Sca-1+], CD9+, CD45-, CD11b-, and CD31-). Brain-derived cells were exposed to mesenchymal differentiation conditions. To determine the locations of these cells within the brain, sections of normal brains were analyzed by immunostaining for Sca-1, CD31, and nerve/glial antigen 2. RESULTS: Cells morphologically similar to mouse BM-MSCs were identified and called brain-derived MSCs (Br-MSCs). Fluorescence-activated cell sorting indicated that the isolated cells had a surface marker profile similar to BM-MSCs, ie, Sca-1+, CD9+, CD45-, and CD11b-. Like BM-MSCs, Br-MSCs were capable of differentiation into adipocytes, osteocytes, and chondrocytes. Immunostaining indicated that Sca-1+ Br-MSCs are located around blood vessels and may represent progenitor cells that serve as a source of mesenchymal elements (eg, pericytes) within the brain. CONCLUSION: Our results indicate that cells similar to BM-MSCs exist in the brain. These Br-MSCs appear to be located within the vascular niche and may provide the mesenchymal elements of this niche. Because MSCs may be part of the cellular response to tissue injury, Br-MSCs may represent targets in the therapy of pathological processes such as stroke, trauma, and tumorigenesis. Copyright (C) by the Congress of Neurological Surgeons

Report of Selective Cortical Infarcts in the Primate Clot Model of Vasospasm After Subarachnoid Hemorrhage 

BACKGROUND: In human autopsy studies, 70% to 80% of patients with aneurysmal subarachnoid hemorrhage (SAH) showed infarcts in cerebral cortex covered by subarachnoid blood. Thus far, no animal model of SAH is known to produce this peculiar infarct pattern, and its pathogenesis remains enigmatic. OBJECTIVE: To investigate whether such infarcts occur in the clot model of SAH in primates. METHODS: We performed a retrospective pathological review of 16 primate brains. In 13 cynomolgus monkeys, a blood clot was placed around the middle cerebral artery after additional removal of the arachnoid membrane from the basal surface of the frontal and temporal cortexes. Three animals underwent sham surgery without placement of a blood clot (controls). The brains were harvested between days 1 and 28 after SAH and examined by a neuropathologist blinded to study group. RESULTS: We identified 2 types of cortical infarcts. A band of selective cortical laminar necrosis parallel to the cortical surface ("horizontal") was found in 5 animals. The second category of cortical lesions had a "vertical" extension. It included wedge-shaped (n = 2) or pillarlike (n = 2) necrosis. Both horizontal and vertical infarcts were located exclusively in areas adjacent to subarachnoid blood. The presence of a cortical infarct did not correlate with the degree of middle cerebral artery vasospasm (r2 = .24, P = .13). CONCLUSION: The presence of cortical infarcts suggests that a modified nonhuman primate model of SAH is suitable to examine the pathogenesis of proximal vasospasm and permits investigation of cortical lesions similar to those reported in patients after SAH. Furthermore, it indicates that direct effects of the blood clot on the brain and microcirculation contribute to the development of cortical infarcts after SAH. Copyright (C) by the Congress of Neurological Surgeons

Effect of Therapeutic Mild Hypothermia on the Genomics of the Hippocampus After Moderate Traumatic Brain Injury in Rats 

BACKGROUND: Traumatic brain injury (TBI), a major cause of morbidity and mortality, is a serious public health concern. OBJECTIVE: To evaluate the effect of mild hypothermia on gene expression in the hippocampus and to try to elucidate molecular mechanisms of hypothermic neuroprotection after TBI. METHODS: Rats were subjected to mild hypothermia (group 1: n = 3, 33[degrees]C, 3H) or normothermia (group 2: n = 3; 37[degrees]C, 3H) after TBI. Six genome arrays were applied to detect the gene expression profiles of ipsilateral hippocampus. Functional clustering and gene ontology analysis were then carried out. Another 20 rats were randomly assigned to 4 groups (n = 5 per group): group 3, sham-normothermia; group 4, sham-hypothermia; group 5, TBI-normothermia; and group 6, TBI-hypothermia. Real-time fluorescent quantitative reverse-transcription polymerase chain reaction was used to detect specific selected genes. RESULTS: We found that 133 transcripts in the hypothermia group were statistically different from those in the normothermia group, including 57 transcripts that were upregulated and 76 that were downregulated after TBI (P < .01). Most of these genes were involved in various pathophysiological processes, and some were critical to cell survival. Analysis showed that 9 gene ontology categories were significantly affected by hypothermia, including the most affected categories: synapse organization and biogenesis (upregulated) and regulation of inflammatory response (downregulated). The mRNA expression of Ank3, Cmbp, Nrxn3, Tgm2, and Fcgr3 was regulated by hypothermia, TBI, or a combination of TBI and hypothermia compared with the sham-normothermia group. Their mRNA expression was significantly regulated by hypothermia in TBI groups. CONCLUSION: Posttraumatic mild hypothermia has a significant effect on the gene expression profiles of the hippocampus, especially those genes belonging to the 9 gene ontology categories. Differential expression of those genes may be involved in the most fundamental molecular mechanisms of cerebral protection by mild hypothermia after TBI. Copyright (C) by the Congress of Neurological Surgeons

Thromboembolic Complications of Elective Coil Embolization of Unruptured Aneurysms: The Effect of Oral Antiplatelet Preparation on Periprocedural Thromboembolic Complication 

OBJECTIVE: We retrospectively evaluated whether antiplatelet preparation lowered the thromboembolic complication rate during the perioperative period. METHODS: We reviewed 328 elective coil embolization procedures in which only microcatheters were used for coiling. No antiplatelet medication was prescribed before the procedure in 95 cases (29%, group 1), whereas antiplatelet therapy was used in 233 cases (71%, group 2; 61 [18.6%] with a single agent [aspirin or clopidogrel] and 172 [52.4%] with both agents). Antiplatelet agents were not given after coiling unless atherosclerosis, severe coil protrusion, or a thromboembolic complication occurred during the procedure. A thromboembolic complication was defined as a procedural thromboembolic event or transient ischemic attack or stroke occurring within 2 days of embolization. RESULTS: Thromboembolic complications occurred in 11 cases (3.4%): 6 (6.3%) in group 1 and 5 (2.1%) in group 2 (P = .085). In 195 cases (59.5%) treated by the single microcatheter technique, the risk of thromboembolic complications was low and not affected by antiplatelet preparation (1.8% [no preparation] vs 2.2% [preparation]; P = 1.000). However, in 133 cases (40.5%) treated by the multiple microcatheter technique, antiplatelet preparation significantly reduced the thromboembolic complication risk by 85.2% (12.8% [no preparation] vs 2.1% [preparation]; odds ratio, 0.148; 95% confidence interval, 0.027-0.798; P = .023). The aneurysms treated by the multiple microcatheter technique had more complex configurations for coiling (P < .001). The risk of hemorrhage was not increased by antiplatelet preparation (P = .171). CONCLUSION: Antiplatelet preparation lowered the periprocedural thromboembolic complication rate in unruptured aneurysms treated by the multiple microcatheter technique and did not increase the risk of hemorrhage. Therefore, antiplatelet preparation can help to reduce complications in patients in whom technical difficulties are expected without the risk of hemorrhage. Copyright (C) by the Congress of Neurological Surgeons

The Effect of Microvascular Decompression in Patients With Multiple Sclerosis and Trigeminal Neuralgia 

BACKGROUND: Trigeminal neuralgia (TN) in patients with multiple sclerosis (MS) is thought to be caused by demyelinating plaques within the nerve root entry zone, the trigeminal nucleus, or the trigeminal tracts. OBJECTIVE: To review our experience of microvascular decompression (MVD) in patients with MS and symptomatic TN. METHODS: All first-time MVDs for symptomatic trigeminal neuralgia in patients with MS performed by the senior author during an 8-year period (1999-2007) in this department were reviewed. The preoperative pain components were differentiated as being 100% episodic pain, > 50% episodic pain, or > 50% constant pain. At follow-up, pain relief was assessed with a standard mail questionnaire; those still having residual pain were further examined in the outpatient clinic or interviewed by phone. RESULTS: Of the 19 MS patients, 15 were available for follow-up. The median observation period was 55 months (range, 17-99 months). At follow-up, 7 of 15 patients (47%) were completely free of their episodic pain, and an additional 4 (27%) had significant relief of episodic pain (ie, worst pain marked as 0 to 3 cm on a 10-cm visual analog scale). Among the subgroup of 8 patients with a constant pain component, all were free of their constant pain, and 4 (50%) were free of their episodic pain. CONCLUSION: In our 8-year experience of doing MVD in MS patients with TN, we found complete and significant relief of episodic TN in a large proportion of patients. Even those with a constant pain component before MVD were completely relieved of their constant pain. Thus, in patients with TN (with or without a constant pain component), the presence of MS should not prevent patients from being offered MVD. Copyright (C) by the Congress of Neurological Surgeons

Outcome for Middle Cerebral Artery Aneurysm Surgery 

OBJECTIVE: To assess in depth the variables contributing to adverse surgical outcome for repair of unruptured middle cerebral artery aneurysms. METHODS: Prospectively collected data between October 1989 and June 2009 were examined retrospectively. Putative risk factors were investigated with univariate and multivariate logistic regression analyses. RESULTS: In this study, 263 patients (339 aneurysms) underwent surgical clipping in 280 operations for unruptured middle cerebral artery aneurysms. The overall surgical mortality and morbidity rate was 5% (95% confidence interval [CI], 2.9-8.3). Multivariate logistic analysis of risk factors revealed that age and aneurysm size were independent predictors of surgical outcome. Patients < 60 years of age with an aneurysm <= 12 mm constituted a low-risk group with a procedure-related combined mortality and morbidity of 0.6% (95% CI, 0-3.8). Patients < 60 years of age with an aneurysm > 12 mm had a procedure-related combined mortality and morbidity of 7.4% (95% CI, 1-24.5). Patients >= 60 years of age with an aneurysm of <= 12 mm had a procedure-related combined mortality and morbidity of 9.3% (95% CI, 4.3-18.3). Patients >= 60 years of age with an aneurysm > 12 mm had a procedure-related combined mortality and morbidity of 22.2% (95% CI, 8.5-45.8). CONCLUSION: Age and size of aneurysm were the only 2 independent predictors of surgical outcome. Copyright (C) by the Congress of Neurological Surgeons

Infected Rathke Cleft Cysts: Distinguishing Factors and Factors Predicting Recurrence 

BACKGROUND: Rathke cleft cysts (RCCs) are benign sellar lesions that are generally asymptomatic but sometimes warrant transsphenoidal drainage. Small case reports have described infected RCCs, but this phenomenon remains uncharacterized. OBJECTIVE: We reviewed RCCs over 23 years at our institution to determine factors predicting infection and recurrence. METHODS: We retrospectively reviewed the magnetic resonance images, laboratory results, microbiology, and pathology of 176 RCC patients (1985-2008) who underwent initial operation at our institution (n = 170) or at another institution followed by recurrence managed at our institution (n = 6). RESULTS: There were 3 RCC categories: cysts cultured intraoperatively during initial surgery (n = 21), cysts not cultured during initial surgery but cultured during subsequent surgery (n = 9), and cysts that were never cultured (n = 146). Cultured cysts were larger (1.6 vs 1.2 cm; P = .002) and had more frequent pituitary dysfunction (76% vs 30%; P < .001) than noncultured cysts. Restricted diffusion was also more common in cultured cysts (50% vs 0%; P = .02). Of cysts cultured at initial or subsequent surgery, 48% and 44%, respectively, had positive cultures (n = 14) and were treated with antibiotics. The most common organisms were Staphylococcus epidermidis (64%) and Propionibacterium acnes (57%). Kaplan-Meier recurrence rates were 13% (culture positive/antibiotic treated), 31% (culture negative/not antibiotic treated), and 9% (noncultured) (P = .002, cultured vs noncultured; P = .002, culture negative/not antibiotic treated vs non-cultured; P = .5 culture positive/antibiotic treated vs noncultured). CONCLUSION: Suspected RCC infection, regardless of culture results, is a strong predictor of recurrence and may warrant antibiotic treatment. With antibiotic treatment, the recurrence rate of infected RCC approaches that of noninfected cysts. The higher recurrence rates reported in other series may reflect underrecognition of occult infection. Copyright (C) by the Congress of Neurological Surgeons

Pituitary Stem Cells: Review of the Literature and Current Understanding 

BACKGROUND: The existence of pituitary stem cells in the adult pituitary gland is supported by such findings as postnatal proliferation, differentiation based on environmental alterations, and development of hormone-producing cells after specific lesions in the pituitary. OBJECTIVE: We discuss which cells in the adult pituitary gland might play a role as pituitary stem cells, the potential for these cells to initiate pituitary adenomas, and possible future clinical implications. METHODS: We reviewed the English literature in search for scholarly articles related to stem cells in the adult pituitary, cells with embryonic profile in the adult gland, mitogenic characteristics of adult pituitary cells, and pituitary adenoma oncogenesis. RESULTS: We identified and analyzed 135 articles related to pituitary stem cells and pituitary development published since 1965. Stem cell characteristics, including renewal, proliferation abilities, and the presence of stem cells markers, have been demonstrated by adult pituitary cells from mammals. However, the proliferation ability observed so far is limited, and the potential of differentiation into hormone-secreting cells remains to be conclusively proven. Stem cell markers have been detected in animal models of pituitary tumorigenesis; however, a direct connection has not been demonstrated. CONCLUSION: Research into the capacity of "pituitary stem cells" to differentiate in vitro and in vivo will clarify the mechanisms for regulation of these cells. As pituitary stem cells are better understood, clinical applications like the treatment of pituitary adenomas and the implantation of pituitary stem cells for hormonal deficiencies may be developed. Copyright (C) by the Congress of Neurological Surgeons

The Development of Neurosurgery at the University of Utah, 1955-2009 

LOCATED IN THE geographic Intermountain West, the Department of Neurosurgery at the University of Utah has undergone remarkable growth and transformation since the appointment of the first full-time clinical faculty member in 1955. The Department has provided broad neurosurgical services to an expanding community while fulfilling its academic mission of pushing the frontiers within neurosurgical subspecialties. The history of neurosurgery in the Salt Lake Valley and the achievements of the Department of Neurosurgery, including the seminal development of early cranial stereotactic devices, are reviewed in this article. Copyright (C) by the Congress of Neurological Surgeons

Effect of Flow Diversion Treatment on Very Small Ruptured Aneurysms 

BACKGROUND: Ruptured aneurysms of < 2 mm are not amenable to endovascular coiling and therefore pose a significant treatment challenge. OBJECTIVE: To test recently introduced flow diverters that allow endovascular reconstruction via another method and may represent a new treatment option for such lesions. PATIENTS AND METHODS: Three female patients presented with acute subarachnoid hemorrhage. An aneurysm of < 2 mm was identified in all patients as the cause of bleeding. The aneurysms were located at the C2 segment of the internal carotid in 2 patients and on the basilar bifurcation in the other. All patients had failed early endovascular treatment attempts. Flow diversion with the SILK flow diverter was offered as an alternative in each patient. RESULTS: SILK deployment successfully eliminated the aneurysms in all 3 instances. One of the aneurysms was excluded from contrast material visualization immediately after stent deployment. Transient thrombotic complication was observed in the case of the basilar artery aneurysm. It resolved with the administration of intraarterial tirofiban. There was no treatment-related morbidity, and none of the aneurysms reruptured after SILK implantation during a clinical follow-up of at least 4 months (range, 4-10 months). Imaging follow-up showed complete vessel remodeling in all cases. CONCLUSION: Flow diversion treatment prevented rebleeding during the follow-up period. Reverse remodeling of the concerned vascular segment with delayed disappearance of the aneurysm was observed in each case. Copyright (C) by the Congress of Neurological Surgeons

Endovascular Management of Symptomatic Spasm of Radial Artery Bypass Graft: Technical Case Report 

OBJECTIVE: To describe the technique of endovascular access for treatment of vasospasm of a radial artery bypass graft from the occipital artery to the M3 branch of the middle cerebral artery (MCA) in a patient with moyamoya disease. CLINICAL PRESENTATION: A 32-year-old woman presented with recurrent right-sided ischemic symptoms in the territory of a previous stroke. Angiographic findings were consistent with moyamoya disease, and a perfusion deficit was identified on computed tomography (CT) perfusion imaging. TECHNIQUE: The patient underwent a left MCA bypass graft for flow augmentation. She returned with an occluded bypass graft, collateralization of the anterior MCA territory through a spontaneous synangiosis, and a severe perfusion deficit in the posterior MCA territory. She underwent a revision bypass graft procedure with the radial artery from the occipital artery stump to the MCA-M3 branch. She developed repeated symptomatic vasospasm of the radial artery graft postoperatively. After systemic anticoagulation, the graft was accessed through the occipital artery, and intra-arterial verapamil was injected. When this failed to resolve the graft spasm, the radial artery graft was accessed with a 0.14-inch Synchro-2 microwire (Boston Scientific, Natick Massachusetts), and sequential angioplasties were performed using over-the-wire balloons from the proximal to distal anastomosis and in the occipital artery stump. A nitroglycerin patch was applied cutaneously over the graft to relieve the vasospasm. RESULTS: No complications occurred. Graft patency with robust flow was observed on the 5-month follow-up angiogram. CONCLUSION: Endovascular techniques can be safely used for salvage of spastic extracranial-intracranial grafts. Copyright (C) by the Congress of Neurological Surgeons

The Birth and Evolution of Neuroscience Through Cadaveric Dissection 

ALTHOUGH INTEREST IN the art of dissection and vivisection has waxed and waned throughout the ages, the past century has seen it accepted as commonplace in medical schools across the country. No other practice in medicine has contributed more to the understanding of neuroanatomy and the neurosciences as dissection of the human cadaver, the origins of which are widely documented to have been in Alexandrian Greece. This article chronicles the fascinating and often controversial use of dissection and vivisection in these fields through the ages, beginning with Herophilus of Alexandria, among the first systematic dissectors in the history of Western medicine. The authors comment on its role in the development of modern neurosurgery and conclude with remarks about use of this educational tool today in the United States. Copyright (C) by the Congress of Neurological Surgeons

Glioblastomas With Giant Cell and Sarcomatous Features in Patients With Turcot Syndrome Type 1: A Clinicopathological Study of 3 Cases 

BACKGROUND: Turcot syndrome (TS) is a rare genetic disorder of DNA mismatch repair predisposing to glioblastoma (GBM) in the type 1 variant. OBJECTIVE: We report the clinicopathological and genetic features of 3 gliomas in TS type 1 patients. METHODS: Three cases were reviewed from our clinical and pathology files at Washington University with the diagnosis of TS 1 and GBM over the past 14 years. All 3 had classic features of GBM, but also demonstrated bizarre multinucleated giant cells and remarkably high mitotic indices. Sarcomatous regions were found in 2. Despite these features, the patients had prolonged survival times of 44, 55, and >29 months (ie, currently alive). Demographic and clinical courses were abstracted from retrospective chart review. Histopathology was reviewed from all cases and reticulin histochemistry was added to identify possible foci of sarcomatous differentiation. RESULTS: All 3 had classic features of GBM, and Ki-67 labeling indices ranged from 18 to 45%. All 3 also showed strong nuclear p53 positivity. Two cases were negative for the isocitrate dehydrogenase 1 (IDH1) mutation, and O 6-Methylguanine methyltransferase promoter methylation was seen in one. Fluorescence in situ hybridization was done using 1p/1q, 19p/19q, centromere 7/epithelial growth factor receptor (EGFR), and PTEN/DMBT1 probes. Focal EGFR amplification was seen in one case, although other common alterations of either primary GBMs or gliomas with prolonged survival (1p/19q codeletion) were lacking. CONCLUSION: We conclude that 1) the giant cell variant of GBM is overrepresented in TS; 2) gliosarcomas may also be encountered; and 3) survival is often favorable, despite histological anaplasia and exuberant proliferation. Copyright (C) by the Congress of Neurological Surgeons

Simple Technique for Intraoperative Angiographic Localization of Small Vascular Lesions 

BACKGROUND: Precise surgical localization of small arteriovenous malformations (AVMs), arteriovenous fistulae (AVFs), and aneurysms located in the distal portions of the intracranial arteries can be difficult OBJECTIVE: We describe a simple and accurate intraoperative angiographic localization technique for small AVMs, AVFs, and distal aneurysms. METHODS: All patients had routine preoperative diagnostic imaging and evaluations, including catheter angiography. Once anesthetized, the patients were prepared for intraoperative angiography following cannulation of the femoral artery. Craniometric landmarks were utilized to approximately localize the lesion. A wire in the shape of a square was placed over the proposed craniotomy site and an angiogram was performed. With use of real-time angiography, the wire localizer was manipulated until the small vascular lesion was visualized entirely within the wire frame, thus defining the extent of the required craniotomy and the surgical trajectory. RESULTS: The wire localizer was used to target small vascular lesions in 9 cases of AVMs, 4 cases of distal middle cerebral artery aneurysms, and 1 case of a diploic AVF. In all 14 cases, the lesion was accurately localized intraoperatively without further image-guided techniques, and there was no change in the craniotomy. There were no intraoperative complications, and all patients had uneventful recoveries. CONCLUSION: Intraoperative angiography with a simple wire localizer can effectively and accurately aid in the planning of surgery for a range of small and distal vascular lesions with virtually no added cost, minimal setup time, and limited potential for technical errors. Copyright (C) by the Congress of Neurological Surgeons

Endoscopic Treatment of Arachnoid Cysts: A Detailed Account of Surgical Techniques and Results 

BACKGROUND: Surgical treatment of arachnoid cysts remains under debate. Although many authors favor endoscopic techniques, others attribute a higher recurrence rate to the endoscope. OBJECTIVE: The authors report their experience with endoscopic procedures for arachnoid cyst. METHODS: All pure endoscopic procedures for arachnoid cysts performed by the authors were analyzed. Particular reference was given to surgical complications and patient outcome in relation to cyst location and endoscopic technique. RESULTS: Sixty-six endoscopic procedures were performed in 61 patients (mean age, 28 years; range, 23 days to 74 years; 35 males, 26 females). The main presenting symptoms were cephalgia (61%), hemisymptoms (18%), and macrocephalus (18%). Cyst location was temporobasal (34%), suprasellar (21%), at the cisterna quadrigemina (18%), paraxial supratentorial (16%), and various (10%). Thirty cystocisternostomies, 14 ventriculocystostomies, 12 cystoventriculostomies, and 10 ventriculocystocisternostomies were performed. The overall clinical success rate was 90%. The endoscopic technique was abandoned in 4 cases (7%). Postoperative complications were found in 16%; there was only one permanent deficit (2%). Five recurrences (8%) occurred up to 7 years after the first procedure. Of the various locations, the temporobasal cysts were the most difficult to treat with lowest clinical success (81%), highest recurrence (19%), and highest complication rate (24%). Of the various endoscopic techniques, ventriculocystostomy and ventriculocystocisternostomy reached the highest success rates with 100%. CONCLUSIONS: Endoscopic techniques provide very good results in arachnoid cyst treatment. The most frequent cyst location is the most difficult to treat. A long-term follow-up is recommended since recurrences can occur many years after the procedure. Copyright (C) by the Congress of Neurological Surgeons

Endocrinopathy, Vision, Headache, and Recurrence After Transsphenoidal Surgery for Rathke Cleft Cysts 

BACKGROUND: Rathke cleft cyst can enlarge and become symptomatic. OBJECTIVE: To review the clinical data and results of all patients treated by the senior author for a Rathke cleft cyst. METHODS: A prospectively maintained surgical database, supplemented with updates from telephone conversations, of all patients presenting to the Barrow Neurological Institute from 1992 to the present was reviewed. RESULTS: Seventy-three patients (17 males, 56 females; mean age, 40 years; range, 5-80 years) underwent 77 resections. The mean length of follow-up was 27 months (range, 0-129 months). Presenting symptoms included headache (75%), followed by endocrinopathy (49%), and visual symptoms (39%). Preoperative chiasmopathy resolved in 75% and improved in 21% of the patients. Patients' preoperative endocrinopathy resolved at various rates, depending on the specific axis (29%-100%). Endocrinopathies were more likely to resolve in females than males. New postoperative endocrinopathies also occurred (0-8%). Headache resolved (68%) or improved (21%) in most patients. No patient had worsened headaches. Eight patients had a recurrence, 4 of whom underwent reoperation. The presence of squamous metaplasia was the only predictor of recurrence. CONCLUSION: Surgical fenestration and/or resection of Rathke cleft cyst via the transsphenoidal approach are a rational choice for surgical management of these lesions when symptomatic. In most cases, visual symptoms and headache can be expected to improve. New persistent endocrine deficits can be expected in a small percentage of patients, but preexisting endocrinopathies resolve in many patients. Copyright (C) by the Congress of Neurological Surgeons

Postoperative Assessment of Clipped Aneurysms With 64-Slice Computerized Tomography Angiography 

BACKGROUND: Multidetector computerized tomography angiography (MDCTA) is now a widely accepted technique for the management of intracranial aneurysms. OBJECTIVE: To evaluate its accuracy for the postoperative assessment of clipped intracranial aneurysms. METHODS: We analyzed a consecutive series of 31 patients that underwent direct surgical clipping procedures of 38 aneurysms. A 64 slice MDCT scanner (Aquilion 64, Toshiba) was used and results were compared with digital subtraction angiographies (DSA). Two independent neuroradiologists analyzed the following data: examination quality, artifacts, aneurysm remnant, and patency of collateral branches. Interobserver agreement, sensitivity, and specificity were calculated. RESULTS: Seventy-nine percent of the aneurysms were located in the anterior circulation. Significant artifacts were found with multiple and cobalt-alloy clips. According to DSA, remnants >2 mm were found in 21% of the cases, and 2 patients had one collateral branch occluded. Sensitivity and specificity of 64-MDCTA for the detection of aneurysm remnants were 50% and 100%, respectively. Sensitivity and specificity of 64-MDCTA for the detection of a significant remnant (>2 mm) and the detection of the occlusion of a collateral branch were, respectively, 67% and 100% and 50% and 100%. No relationship was found with the location, type, shape, size, or number of clips, but missed remnants tended to be larger with cobalt-alloy clips. CONCLUSIONS: 64-MDCTA is a valuable technique to assess the presence of a significant postoperative remnant in single titanium clip application cases and might be useful for long-term follow-up. DSA remains the most accurate postoperative radiological examination. Copyright (C) by the Congress of Neurological Surgeons

Endovascular Treatment of Side Wall Aneurysms Using a Liquid Embolic Agent: A US Single-Center Prospective Trial 

OBJECTIVE: Onyx HD-500 is a liquid embolic agent consisting of ethylene vinyl alcohol copolymer dissolved in dimethylsulfoxide and mixed with tantalum. This viscous embolic agent was designed to treat intracranial side wall aneurysms, but there have been no prospective published series from the United States. From this early experience, we developed several protocol revisions, technical details, and clinical pearls that have not been published for liquid embolic embolization of aneurysms. CLINICAL PRESENTATION: We present our single-center prospective series of patients treated with Onyx HD-500 from a multicenter, randomized, controlled trial. Thirteen patients received Onyx HD-500, and their ages ranged from 43 to 81 years. Twelve patients had aneurysms on the internal carotid artery, and 1 patient had an aneurysm the vertebral artery. Every patient had an immediate postangiographic result with 90% or more occlusion by an independent core laboratory assessment. In 1 patient, the Onyx HD-500 injection was aborted, and the aneurysm was embolized with coils. Eleven of 13 patients (85%) underwent 6-month follow-up angiography that demonstrated persistent durable occlusion with no recanalization. There was 1 complication (8%) and no deaths. CONCLUSION: This is the only prospective series of intracranial aneurysms treated with Onyx HD-500 in the United States. This is also the first publication that describes detailed procedure techniques, recommended protocol revisions, lessons learned from early complications, clinical pearls, and advantages and disadvantages of liquid embolic embolization of aneurysms. Copyright (C) by the Congress of Neurological Surgeons

Intracranial and Spinal Metastases From Eccrine Mucinous Carcinoma: Case Report 

BACKGROUND AND IMPORTANCE: Mucinous eccrine carcinoma (MEC) is a rare but distinct type of sweat gland tumor. MECs tend to recur locally, and their spread to distant organs is very uncommon. This article describes the first case of MEC metastasizing to the brain and the spine. CLINICAL PRESENTATION: A 45-year-old female presented with a 2-year history of a scalp mass in the occipital area with lymph node spread. She underwent excision of the mass and neck lymph node dissection. Pathology confirmed the diagnosis of MEC. Postoperatively, she received radiation to the involved areas. Four years later the patient presented with left hemiparesis and underwent craniotomy for gross total resection of the metastasis. This recurred after 2.5 years and she underwent another craniotomy for gross total resection followed by whole brain radiation. In addition, the patient had metastases to T11 vertebral body and the left C6 to 7 neural foramen. Moreover, the patient developed leptomeningeal disease in the spine. The metastases to the spine were treated with radiation therapy. The patient died 1.5 years later. CONCLUSION: Even though it is rare for MEC to spread to distant organs, physicians should be aware of the risk of metastatic invasion of the brain and spine and be vigilant about surveillance of these sites. MEC metastases to the brain should be treated aggressively with surgical resection followed by stereotactic radiosurgery to the tumor bed. Spine metastases should be treated with a combination of surgery and image-guided radiation therapy, depending on the degree of cord compression from epidural metastatic disease. Copyright (C) by the Congress of Neurological Surgeons

Changes in Functional Magnetic Resonance Imaging Cortical Activation After Decompression of Cervical Spondylosis: Case Report 

BACKGROUND AND IMPORTANCE: Spinal cord compression may induce cortical reorganization. This study follows a patient with cervical spondylotic myelopathy to investigate changes in cortical activation before and after decompressive surgery. The relationship with functional recovery is also described. CLINICAL PRESENTATION: A 37-year-old right-hand-dominant man presented a 1-month history of rapidly worsening right-hand clumsiness, right-sided hemiparesis, and gait difficulties. Physical examination confirmed severe right-sided weakness, impaired dexterity, hyperreflexia, and wide-based gait. The patient underwent blood oxygenation level-dependent functional magnetic resonance imaging at 4 T. Images were obtained before and 6 months after an anterior cervical discectomy with insertion of an artificial disk. Blood oxygenation level-dependent functional magnetic resonance imaging was used to detect changes in cortical activation over time during a finger-tapping (motor) paradigm. Improvement in clinical function was recorded with validated clinical tools, including the Japanese Orthopedic Association scale for cervical spondylotic myelopathy, the Nurick neurological function score, and the Neck Disability Index, along with clinical examination. CONCLUSION: After decompressive cervical spine surgery in a patient with cervical spondylotic myelopathy, functional magnetic resonance imaging detected increased cortical activation in the primary motor cortex during finger tapping. These changes occurred concomitantly with improvement in motor function. Upper- and lower-extremity motor subscores of the Japanese Orthopedic Association scale demonstrated 40% and 43% improvement, respectively. These observations suggest that cortical reorganization or recruitment may accompany the recovery of function after spinal cord injury. Copyright (C) by the Congress of Neurological Surgeons

Iatrogenic Sacroiliac Joint Syndrome After Percutaneous Pedicle Screw Fixation at the L5-S1 Level: Case Report 

BACKGROUND AND IMPORTANCE: This article reports an unexpected complication of percutaneous pedicle screw fixation at the L5-S1 level. CLINICAL PRESENTATION: We describe a 66-year-old man who underwent anterior lumbar interbody fusion followed by percutaneous pedicle screw fixation at the L5-S1 level. The Sextant pedicle screw system was used. The patient experienced postoperative sacroiliac joint syndrome caused by the screw head and rod tip. In the immediate postoperative period, the preoperative right-side leg pain improved, but the patient complained of left-side buttock and leg pain. The left-side screws were removed, and after revision surgery, the left-side pain disappeared. However, at that time, right-side pain recurred. We found that the screw head and rod had violated the iliac crest and the sacroiliac joint, causing referred pain rather than radicular pain. After the screw head was repositioned and the rod was replaced with a new shorter rod with a blunt end, the patient's symptom was relieved. CONCLUSION: Surgeons should be aware of this unprecedented adverse effect when planning percutaneous pedicle screw fixation at the L5-S1 level. An android pelvis with a narrow and high iliac crest can be a risk factor. Careful preoperative evaluation and more accurate surgical technique are needed to prevent this type of complication. Copyright (C) by the Congress of Neurological Surgeons

Malignant Transformation of Intramedullary Melanocytoma: Case Report 

OBJECTIVE: Meningeal melanocytomas are low-grade primary melanocytic tumors with benign histological features and a favorable clinical prognosis. Transition from meningeal melanocytoma to primary melanoma of the central nervous system is exceptionally rare, with only 5 cases having been previously reported. Here, we discuss a case of malignant transformation of an intramedullary melanocytoma to primary melanoma and review the pertinent literature. CLINICAL PRESENTATION: A 79-year-old woman presented with progressive paresis in the lower limbs followed by sphincter dysfunction. Magnetic resonance imaging scans disclosed an intramedullary lesion located at the T10-T11 level. INTERVENTION: The patient underwent subtotal resection of an intermediate-grade melanocytoma. Two years later, the tumor recurred locally, and the patient underwent additional surgery to remove the intramedullary mass. The histological findings of the tumor were consistent with an intramedullary malignant melanoma. CONCLUSION: The malignant transformation of melanocytic tumors of the central nervous system may occur years after surgical treatment, and its incidence remains unknown. Emphasis should be placed on the importance of careful and continued follow-up monitoring of the tumor. Copyright (C) by the Congress of Neurological Surgeons

Clear Cell Meningiomas: Three Case Reports With Genetic Characterization and Review of the Literature 

BACKGROUND AND IMPORTANCE: Intracranial clear cell meningioma is very rare. We present 3 cases of intracranial clear cell meningiomas genetically characterized by comparative genomic hybridization with a review of the literature. CLINICAL PRESENTATION: Patient 1 is a 38-year-old woman with a petroclival tumor. Patient 2 is a 60-year-old man with a tumor at the foramen magnum. Patient 3 is a 60-year-old man with a tumor at the posterior clinoid process. Gross total resection was performed in patients 1 and 2. Patient 1 has been free from recurrence for 10 years. Patient 2 had a tumor recurrence at 14 months after the operation. After partial resection, conventional radiotherapy was given, and there was no tumor regrowth at 2 years after radiotherapy. Subtotal resection was performed in patient 3, and no regrowth was detected for 3 months. Histologically, all tumors were composed of cells with clear cytoplasm reactive for periodic acid-Schiff and diagnosed as clear cell meningioma. The MIB-1 and p53 staining indexes were 1.8, 1.7, and 5.6 and 1.1, 1.0, and 5.5, respectively. Comparative genomic hybridization revealed no chromosomal number aberrations in patient 1, numerous losses and gains including loss of chromosome 1 in patient 2, and loss of only 22q in patient 3. Because staining indexes of MIB-1 and p53 were equivalent in 2 patient (patients 1 and 2) with a long follow-up period, the contrary clinical courses are likely associated with genetic characteristics. CONCLUSION: To the best of our knowledge, this is the first report that suggests association between tumor behavior and genetic characteristics in clear cell meningiomas. Copyright (C) by the Congress of Neurological Surgeons

Primary Non-Hodgkin's Lymphoma of the Radial Nerve: Case Report 

OBJECTIVE: Primary lymphomas of peripheral nerves are extremely rare, with the bulk of the literature being case reports. The nerve most commonly affected is the sciatic nerve, with 9 cases reported. To date, there are no reports in the English literature of isolated involvement of the radial nerve by a primary lymphoma. CLINICAL PRESENTATION: A 69-year-old woman with a history of osteoporosis, irritable bowel disease, asthma, and Graves' disease presented with a 6-month history of paresthesia in her left superficial sensory radial nerve territory, weakness of thumb extension, and localized pain and swelling in the cubital fossa. Examination showed a painful tender mass in the line of the radial nerve in the cubital fossa, grade 4/5 supination, grade 4-/5 extensor carpi radialis longus and extensor carpi ulnaris, and grade 3/5 finger and thumb extension, all consistent with a radial nerve lesion at the level of the cubital fossa. Ultrasonography and computed tomography confirmed an intraneural tumor. Surgery revealed radial intraneural tumor just after the branch to the extensor carpi radialis longus. It was clearly an infiltrating lesion with no plane between tumor and nerve fascicles. Frozen section confirmed malignancy, and an incomplete excision was performed. Histopathology revealed diffuse large B-cell lymphoma. Surgery was followed with negative staging and a chemotherapy program. CONCLUSION: Primary B-cell lymphoma of the peripheral nerve is exceedingly rare and to date has not been reported as an isolated occurrence in the radial nerve. We present a patient who is alive and disease free 65 months after incomplete excision and limited chemotherapy. Copyright (C) by the Congress of Neurological Surgeons

Vertebral Artery Injury During Cervical Discectomy and Fusion in a Patient With Bilateral Anomalous Arteries in the Disc Space: Case Report 

OBJECTIVE: Our goal was to increase the safety of anterior cervical discectomy, a routine surgery performed by neurosurgeons worldwide, in the face of vertebral artery (VA) anomalies. CLINICAL PRESENTATION: A 59-year-old woman had an intraoperative injury of the left VA during elective anterior cervical discectomy and fusion from C3 to 7. Retrospective analysis of her magnetic resonance images showed bilateral anomalous VAs. Intervention postoperatively, a pseudoaneurysm developed that was subsequently coiled. The patient underwent embolization of the pseudoaneurysm and sacrifice of the parent vessel by endovascular neurosurgical techniques. She had no neurological sequelae but did have some difficulty swallowing. CONCLUSION: Radiologists, neuroradiologists, and surgeons should note the location and course of the VA in their routine evaluation of cervical magnetic resonance images. Neuroradiologists should alert surgeons to the possibility of anomalous VAs that are at risk of injury during surgery. Ultimately, it remains the responsibility of the surgeon to carefully review the images, assess for vascular anomalies, and plan the surgery accordingly. Copyright (C) by the Congress of Neurological Surgeons

True Aneurysm on the Posterior Meningeal Artery Associated With a Dural Arteriovenous Fistula: Case Report 

BACKGROUND: We report an unusual case of a true dural aneurysm arising from the posterior meningeal artery that fed a symptomatic dural arteriovenous fistula located at the right transverse-sigmoid sinus junction. CLINICAL PRESENTATION: A 29-year-old right-handed white woman presented with aneurysmal dilatation of hypertrophied posterior meningeal artery feeding a partially treated dural arteriovenous fistula. INTERVENTION: The aneurysm, which measured approximately 3 mm in width and 5 mm in length, was located in the intracranial space with a thin-walled dome projecting toward the cerebellum. Its afferent and efferent vessels were identified, secured, and the lesion was excised en bloc. CONCLUSION: A thorough evaluation of all diagnostic studies should be performed for patients with vascular malformations to help identify these or other unusual lesions that may aid in the risk stratification process and management plan. Copyright (C) by the Congress of Neurological Surgeons