Author: cba

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Long-term survivors of glioblastoma: clinical features and molecular analysis

Acta Neurochir (2009) 151:1349–1358. DOI 10.1007/s00701-009-0387-1

Glioblastoma is a highly lethal neoplasm with a median survival of 12–14 months; only 2–5% of patients survive >3 years.

Methods At our institute, patients with glioblastoma are initially treated with maximum tumor resection followed by radiation and the intravenous injection of nimustine hydrochloride (ACNU).

Results Using this strategy, 18 of 123 (14.6%) patients treated at our hospital survived >3 years; 7 manifested no recurrence, and the other 11 had early recurrence and received additional therapies. To identify factors associated with prolonged survival, we compared these patients with 21 short-term (<1.5 years) glioblastoma survivors. In the long-term survivors, the MGMT promoter methylation was significantly more frequent. The rate of p53 mutation was lower, and the rate of PTEN mutations and the proliferation index were slightly higher in short-term survivors.

Conclusion By multivariate analysis,  we found that a younger age and MGMT promoter methylation were significant favorable factors in patients with glioblastoma.

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Limits of endoscopic treatment of sylvian arachnoid cysts in children

Childs Nerv Syst. DOI 10.1007/s00381-009-0977-5

The optimal surgical management of sylvian arachnoid cysts is debated. We present our experience in children who were treated endoscopically, focusing on the limits and complications of this approach.

Materials and methods: Seventeen children with a temporo- sylvian arachnoid cyst have been treated using a purely temporal endoscopic approach.

Results: In all but one case, the recognition of anatomical landmarks was obtained at the insertion of the endoscope. In one child, the orientation and opening of the basal cisterns were more difficult due to the thickness and opacity of the membranes. Nevertheless, it was possible to perform the cysto-cisternostomy endoscopically in all children with several stomies in 13. In one child, a venous bleeding occurred. There were no other intraoperative complications. There were no postoperative cerebrospinal fluid leaks. In two patients, a symptomatic subdural collection developed which required a transient subdural-peritoneal shunt. No subdural collection was noted on a delayed follow-up (mean, 23 months). Preoperative symptoms related to the mass effect exerted by the cyst resolved in all children. Two children presented a recurrence, 12 and 20 months after endoscopic surgery, respectively. At the redo-endoscopy, the stomies were found to be closed. Their reopening resulted in the disappearance of the symptoms.

Conclusions: An endoscopic approach can be used safely in the management of sylvian arachnoid cysts. An effective opening of the deep arachnoid membranes into the basal cisterns could be performed in all patients with the resolution of the preoperative symptoms. However, the long-term efficacy of the stoma needs to be assessed.

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Craniotomy for resection of meningioma in the elderly: a multicenter, prospective analysis from the National Surgical Quality Improvement Program

J Neurol Psychiatry. DOI:10.1136/jnnp.2009.185074

Whether there is an increased surgical risk in elderly patients who undergo craniotomy for meningioma resection, remains a point of controversy. Utilizing multicenter, prospective data from the National Surgical Quality Improvement Program, the present study sought to address this controversy.

All patients who underwent a craniotomy for resection of intracranial meningioma between 1997 and 2006 at 123 VA hospitals around the country were included. After controlling for preoperative factors such as ASA class, race, diabetes mellitus, disseminated cancer, tobacco use, tumor location, and functional health status in a multivariate logistic regression model, the effect of elderly age (age greater than 70 years) on 30-day mortality was determined.

Our study included 1,281 patients who underwent surgical resection of an intracranial meningioma. The elderly cohort, represented 21.2% (n=258) of our total study population. Elderly patients had a higher 30-day mortality (12.0%) than younger subjects (4.6%) (P < 0.0001). Similarly, elderly patients were more likely to have one or more complications (29.8% vs. 13.1%, P < 0.0001). Multivariate logistic regression identified age, functional status, preoperative disseminated cancer, and tumor location as important predictors of 30-day mortality. After controlling for preoperative comorbidities and risk factors, the odds of perioperative mortality in elderly patients were 3 times that of younger patients (95% CI = 1.7 – 5.3, P = 0.0102).

After carefully controlling for various patient characteristics, ASA class and functional status, elderly patients have poorer outcome after surgical resection of intracranial meningioma than younger subjects.

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Detection of changes in cerebrospinal fluid space in idiopathic normal pressure hydrocephalus using voxel-based morphometry

Neuroradiology DOI 10.1007/s00234-009-0610-z

We attempted to detect alterations in the cerebrospinal fluid (CSF) space in patients with idiopathic normal pressure hydrocephalus (iNPH) using voxel-based morphometry (VBM).

Methods. We obtained sagittal volume images of the entire head by three-dimensional T1-weighted magnetic resonance imaging and compared the regional distribution of CSF in 12 patients with iNPH, 14 patients with Alzheimer’s disease (AD), and 17 healthy individuals using VBM with automatically extracted CSF objects.

Results. VBM demonstrated significant widening at the lateral ventricles and Sylvian fissures and narrowing of the CSF space at the high convexity/midline areas in iNPH patients, compared to the AD patients and healthy controls (p<0.05, after correction with a false-discovery rate). In addition, the ratio of the CSF volume in the lateral ventricle/Sylvian fissure area to that in the high convexity/midline area in iNPH patients (3.9 ± 1.2) was remarkably greater than that in AD patients (1.2 ± 0.3) ANOVA, p < 0.001; post hoc Tukey’s test, p < 0.001); we could discriminate iNPH patients from those in the other two groups without any overlap, when using a cutoff level of 1.9.

Conclusion. VBM using CSF objects can be used to delineate the characteristic alteration of the CSF space in iNPH patients, which has been evaluated by visual interpretation.

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Primary CNS lymphoma in the elderly: temozolomide therapy and MGMT status

J Neurooncol. DOI 10.1007/s11060-009-0032-0

This retrospective series explores temozolomide monotherapy in elderly patients with primary CNS lymphoma (PCNSL) and severe comorbidities. In 17 patients (62–90 years old), the complete response rate was 47%, median progression-free survival was 5 months, and median overall survival was 21 months. Five of 17 patients (29.4%) had prolonged responses for at least 12 months and survived for more than 24 months. Three of these patients had a methylated O6-methylguanine-DNA methyltransferase (MGMT) promoter, while the MGMT status was not assessable in the remaining two patients.

Temozolomide monotherapy appears to be effective in a subgroup of elderly PCNSL patients and deserves further evaluation.

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Basioccipital hypoplasia in Chiari malformation Type I

J Neurosurg 111:1046–1052, 2009. DOI: 10.3171/2009.2.JNS08284

The chronic tonsillar herniation defining Chiari malformation Type I (CMI) is thought to result from overcrowding of a normally developing hindbrain within a congenitally small posterior cranial fossa (PCF) due to occipital hypoplasia. The goals in the present study were to authenticate the cranioencephalic disproportion in a group of patients with CMI and to discuss new developmental aspects according to which part of the occipital bone was underdeveloped.

Methods. The authors retrospectively examined a group of 17 patients with CMI. Measurements of osteotento- rial and neural structures of the PCF were made on MR images of the brain. The results were compared with findings in 30 healthy controls by using the Mann-Whitney U-test.

Results. Dimensions of the neural structures did not differ between the 2 groups of patients. The mean length of the basiocciput was significantly shorter in the CMI group (19.4 mm) compared with the control group (25.7 mm; p = 0.0003). The mean diameter of the foramen magnum was larger in the CMI group, but this difference was not statistically significant. The dimensions of the supraocciput and the mean angle of the cerebellar tentorium were identical in the 2 groups.

Conclusions. Data in this study support the idea that occipital hypoplasia is the main cause of overcrowding within the PCF. Basioccipital shortness is a cardinal feature of the resultant shallow PCF and could proceed from a congenital disorder of the cephalic mesoderm of the parachordal plate or occur later in the infancy because of prema- ture stenosis of the sphenooccipital synchondrosis

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Efficacy of antibiotic-impregnated shunt catheters in reducing shunt infection: data from the United Kingdom Shunt Registry

J Neurosurg Pediatrics 4:389–393, 2009. (DOI: 10.3171/2009.4.PEDS09210)

In recent years CSF shunt catheters impregnated with rifampicin and clindamycin have been introduced to the United Kingdom (UK) market. These catheters have been shown to be effective in vitro against cultures of Staphylococcus epidermidis. The authors used data collected by the UK Shunt Registry to assess the efficacy of antibiotic-impregnated catheters (AICs) against shunt infection by using a matched-pair study design.

Methods. The UK Shunt Registry contains data on nearly 33,000 CSF shunt-related procedures. The authors identified 1139 procedures in which impregnated catheters had been used, and accurate information was known about diagnosis, number of revisions, sex, and age in these cases. The database was ordered chronologically and searched forward and backward for cases with these same characteristics but involving conventional catheters. Matches were found for 994 procedures.

Results. Among the 994 procedures in which AICs had been used, 30 shunts were subsequently revised because of shunt infection. Among the 994 controls, 47 were subsequently revised for infection (p = 0.048, chi-square test).

Conclusions. The UK Shunt Registry does not collect data on causative organisms, and the surgeon is relied on entirely for the diagnosis of infection. However, with the large number of matched pairs evaluated, the authors attempted to reduce bias to a minimum. Their data suggest that AICs have the potential to significantly reduce shunt infections.


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Surgical results of cervical myelopathy in patients older than 80 years of age

J Neurosurg Spine 11:421–426, 2009. DOI: 10.3171/2009.4.SPINE08584

In this prospective analysis the authors describe the clinical results of surgical treatment in patients > 80 years of age in whom spinal function was evaluated with motor evoked potential (MEPs) monitoring.

Methods. The authors included 57 patients > 80 years of age who were suspected of having cervical myelopathy. The mean age of the patients was 83.0 years (range 80–90 years). The central motor conduction time (CMCT) was calculated from the latencies of the MEPs following transcranial magnetic stimulation and from M and F waves fol- lowing peripheral nerve stimulation.

Results. Preoperative electrophysiological evaluation demonstrated significant elongation of CMCT or abnor- malities in MEP waveforms in 37 patients (65%), and 35 patients of these underwent laminoplasty. In 30 patients cervical spondylotic myelopathy was diagnosed and 5 patients ossification of the posterior longitudinal ligament was diagnosed. The preoperative mean Japanese Orthopaedic Association Scale score was 8.6 (range 3–12.5) and the mean postoperative score was 12.6 (range 6–14.5) with an average recovery rate of 45% (range −21 to 100%). There were no major complications in any of the patients during the operative period and there were no cases of death resulting from operative intervention.

Conclusions. Sufficient clinical results are expected even in patients with myelopathy who are older than 80 years of age, provided the patients are correctly selected by electrophysiological evaluation with MEPs and CMCT.


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Three-dimensional simulation for aneurysm surgery

Neurosurgery 65:719–726, 2009 DOI: 10.1227/01.NEU.0000354350.88899.07

OBJECTIVE: With improvements in endovascular techniques, fewer aneurysms are treated by surgical clipping, and those aneurysms targeted for open surgery are often complex and difficult to treat. We devised a hollow, 3-dimensional (3D) model of individual cerebral aneurysms for preoperative simulation and surgical training. The methods and initial experience with this model system are presented.

METHODS:The 3D hollow aneurysm models of 3 retrospective and 8 prospective cases were made with a prototyping technique according to data from 3D computed tomographic angiograms of each patient. Commercially available titanium clips used in our routine surgery were applied, and the internal lumen was observed with an endoscope to confirm the patency of parent vessels. The actual surgery was performed later.

RESULTS: In the 8 prospective cases, the clips were applied during surgery in the same direction and configuration as in the preoperative simulation. Fine adjustments were necessary in each case, and 2 patients needed additional clips to occlude the atherosclerotic aneurysmal wall. With these 3D models, it was easy for neurosurgical trainees to grasp the vascular configuration and the concept of neck occlusion. Practicing surgery with these models also improved their handling of the instruments used during

aneurysm surgery, such as clips and appliers.

CONCLUSION: Using the hollow 3D models to simulate clipping preoperatively, we could treat the aneurysms confidently during live surgery. These models allow easy and concrete recognition of the 3D configuration of aneurysms and parent vessels.

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Intraoperative mapping and monitoring of brain functions for the resection of low-grade gliomas

Neurosurg Focus 27 (4):E4, 2009. (DOI: 10.3171/2009.8.FOCUS09137)

Low-grade gliomas ([LGGs] WHO Grade II) are slow-growing intrinsic cerebral lesions that diffusely infiltrate the brain parenchyma along white matter tracts and almost invariably show a progression toward malignancy. The treatment of these tumors forces the neurosurgeon to face uncommon difficulties and is still a subject of debate. At the authors’ institution, resection is the first option in the treatment of LGGs. It requires the combined efforts of a multidisciplinary team of neurosurgeons, neuroradiologists, neuropsychologists, and neurophysiologists, who together contribute to the definition of the location, extension, and extent of functional involvement that a specific lesion has caused in a particular patient. In fact, each tumor induces specific modifications of the brain functional network, with high interindividual variability. This requires that each treatment plan is tailored to the characteristics of the tumor and of the patient. Consequently, surgery is performed according to functional and anatomical boundaries to achieve the maximal resection with maximal functional preservation. The identification of eloquent cerebral areas, which are involved in motor, language, memory, and visuospatial functions and have to be preserved during surgery, is performed through the intraoperative use of brain mapping techniques. The use of these techniques extends surgical indications and improves the extent of resection, while minimizing the postoperative morbidity and safeguarding the patient’s quality of life.

In this paper the authors present their paradigm for the surgical treatment of LGGs, focusing on the intraoperative neurophysiological monitoring protocol as well as on the brain mapping technique. They briefly discuss the results that have been obtained at their institution since 2005 as well as the main critical points they have encountered when using this approach.

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Cross-sectional magnetic resonance imaging study of lumbar disc degeneration in 200 healthy individuals

J Neurosurg Spine 11:501–507, 2009. (DOI: 10.3171/2009.5.SPINE08675)

Object. The current cross-sectional observational MR imaging study aimed to investigate the prevalence and risk factors of lumbar disc degeneration in a healthy population and to establish the baseline data for a prospective longitudinal study.

Methods. Two hundred healthy volunteers participated in this study after providing informed consent. The status of lumbar disc degeneration was assessed by 3 independent observers, who used sagittal T2-weighted MR imaging. Demographic data collected included age, sex, body mass index, episode(s) of low-back pain, smoking status, hours of standing and sitting, and Roland-Morris Disability Questionnaire scores. There were 68 men and 132 women whose mean age was 39.7 years (range 30–55 years). Eighty-two individuals (41%) were smokers, and the Roland- Morris Disability Questionnaire scores were averaged to 0.6/24.

Results. The prevalence of disc degeneration was 7.0% in L1–2, 12.0% in L2–3, 15.5% in L3–4, 49.5% in L4–5, and 53.0% in L5–S1. A herniated disc was observed at the corresponding levels in 0.5, 3.5, 6.5, 25.0, and 35.0% of cases respectively. Spondylolisthesis was observed in < 3% of this population. Multiple logistic regression analysis demonstrated that age and hours sitting were significantly related to L4–5 disc herniation. Episode of low-back pain, smoking status, body mass index, and hours standing did not affect the prevalence of disc degeneration.

Conclusions. The current study established the baseline data of lumbar disc degeneration in a 30- to 55-year-old healthy population for a prospective longitudinal study. Hours spent sitting significantly increased the prevalence of disc herniation, but episode of low-back pain, smoking status, obesity, and standing hours were not significant risk factors.

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Intracranial infectious aneurysms: a comprehensive review

Neurosurg Rev DOI 10.1007/s10143-009-0233-1

Intracranial infectious aneurysms, or mycotic aneurysms, are rare infectious cerebrovascular lesions which arise through microbial infection of the cerebral arterial wall. Due to the rarity of these lesions, the variability in their clinical presentations, and the lack of population-based epidemiological data, there is no widely accepted management methodology. We undertook a comprehensive literature search using the OVID gateway of the MEDLINE database (1950–2009) using the following keywords (singly and in combination): “infectious,” “mycotic,” “cerebral aneurysm,” and “intracranial aneurysm.” We identified 27 published clinical series describing a total of 287 patients in the English literature that presented demographic and clinical data regarding presentation, treatment, and outcome of patients with mycotic aneurysms. We then synthesized the available data into a combined cohort to more closely estimate the true demographic and clinical characteristics of this disease. We follow by presenting a comprehensive review of mycotic aneurysms, highlighting current treatment paradigms. The literature supports the administration of antibiotics in conjunction with surgical or endovascular intervention depending on the character and location of the aneurysm, as well as the clinical status of the patient. Mycotic aneurysms comprise an important subtype of potentially life-threatening cerebrovascular lesions, and further prospective studies are warranted to define outcome following both conservative and surgical or endovascular treatment.


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Hyponatremia in Neurosurgical Patients: Clinical Guidelines Development

Neurosurgery. 65(5):925-936, November 2009. DOI: 10.1227/01.NEU.0000358954.62182.B3

OBJECTIVE: Neurosurgical patients have a high risk of hyponatremia and associated complications. We critically evaluated the existing literature to identify the determinants for the development of hyponatremia and which management strategies provided the best outcomes.

METHODS: A multidisciplinary panel in the areas of neurosurgery, nephrology, critical care medicine, endocrinology, pharmacy, and nursing summarized and classified hyponatremia literature scientific studies published in English from 1950 through 2008. The panel’s recommendations were used to create an evaluation and treatment protocol for hyponatremia in neurosurgical patients at the University of Florida.

RESULTS: Hyponatremia should be further investigated and treated when the serum sodium level is less than 131 mmol/L (class II). Evaluation of hyponatremia should include a combination of physical examination findings, basic laboratory studies, and invasive monitoring when available (class III). Obtaining levels of hormones such as antidiuretic hormone and natriuretic peptides is not supported by the literature (class III). Treatment of hyponatremia should be based on severity of symptoms (class III). The serum sodium level should not be corrected by more than 10 mmol/L/d (class III). Cerebral salt wasting should be treated with replacement of serum sodium and intravenous fluids (class III). Fludrocortisone may be considered in the treatment of hyponatremia in subarachnoid hemorrhage patients at risk of vasospasm (class I). Hydrocortisone may be used to prevent natriuresis in subarachnoid hemorrhage patients (class I). Hyponatremia in subarachnoid hemorrhage patients at risk of vasospasm should not be treated with fluid restriction (class II). Syndrome of inappropriate antidiuretic hormone may be treated with urea, diuretics, lithium, demeclocycline, and/or fluid restriction (class III).

CONCLUSION: The summarized literature on the evaluation and treatment of hyponatremia was used to develop practice management recommendations for hyponatremia in the neurosurgical population. However, the practice management recommendations relied heavily on expert opinion because of a paucity of class I evidence literature on hyponatremia.

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Primary Intramedullary Tumors of the Spinal Cord

SPINE Volume 34, Number 22S, pp S69 –S77, 2009

Study Design. Clinically based systematic review.

Objective. To define optimal clinical care for primary intramedullary spinal cord tumors using a systematic re- view with expert opinion.

Methods. Focused questions on the treatment of primary intramedullary spinal cord tumors were refined by a panel of spine oncology surgeons, medical and radiation oncologist. Keyword were searched through Medline database and pertinent abstracts and manuscripts obtained. The quality of literature was rated as high, moderate, low, or very low. Using the GRADE evidence based review system the proposed questions were answered using the literature review and expert opinion. These treatment recommendations were then rated as either strong or weak based on the quality of evidence and clinical expertise.

Results. The literature searches revealed low and very low quality evidence with no prospective or randomized studies. The MEDLINE search engine returned 9000 articles which was restricted to articles about human subjects and written in the English language. The subsequent search resulted in a return of: “spinal cord tumor” (5053), “ependymoma” (580), “astrocytoma” (420), and “glioma” (235) articles. Seventeen articles referenced timing of surgical intervention and symptomatology for intramedullary spinal cord tumors. One hundred fifty-eight chemotherapy and 183 radiation therapy articles for intramedullary spinal cord tumors were reviewed.

Conclusion. The most important factor in determining the IMSCT patient’s long-term neurologic and functional outcome after surgery is the patient’s preoperative neurologic status. However, this must be taken in the context of the underlying tumor histology. Therefore, resection is reserved for progressive neurologic decline and serial monitoring for asymptomatic individuals. Adjuvant therapy is an option for high grade astrocytomas (WHO grades 3–4).


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Removal of giant extraforaminal dumbbell tumors of cervical spine

The Spine Journal 9 (2009) 822–829. doi:10.1016/j.spinee.2009.06.023

Removal of cervical dumbbell tumors can be particularly challenging because of unique exposure requirements and proximity of the vertebral artery (VA). There are no reports describing the treatment of giant cervical spine dumbbell tumors (CSDTs).

PURPOSE: To introduce an extensive posterolateral approach to CSDTs involving total lateral mass resection and laminectomy.

STUDY DESIGN: Prospective study of all the patients with multilevel CSDTs treated by  this new procedure between December 2002 and March 2006.

PATIENT SAMPLE: Sixteen patients (3 men and 13 women) with CSDTs underwent the procedure we describe. The follow-up periods ranged from 9 to 51 months (average 9 months). Average age at surgery was 45 years (range 23–68 years).

OUTCOME MEASURES: Axial symptoms and Japanese Orthopedic Association scores were recorded. Pre- and postoperative ranges of neck motion were measured on lateral flexion and extension radiographs.

METHODS: After making a midline incision, we preferred exposing the extraforaminal component of the tumor before performing a semilaminectomy and lateral mass resection. Any lateral extensión of a tumor can be attained by detachment of the adjacent three or more segments of the lateral mass muscle insertion. The most lateral portion can be separated beneath the tumor’s superficial muscle flap, and then when the tumor is retracted medially, the whole portion of the lateral component can be totally exposed. We then performed total lateral mass resection and laminectomy to expose the tumor at the foramina and cervical canal.

RESULTS: We were able to completely resect the tumors in every patient. The average duration of surgery was 150 minutes. Blood loss was minimal (average 400 mL). All patients were monitores for a minimum of 9 months (range 9–51 months; mean 28 months). The follow-up period was uneventful, and no patients developed spinal instability.

CONCLUSIONS: Extensive posterolateral exposure enables surgeons to reach the lateralmost portion of CSDTs and also facilitates septation of the VA and resection of vertebral body encroachment of the tumor.


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Improving the prognosis for patients with glioblastoma: the rationale for targeting Src

J Neurooncol (2009) 95:151–163 DOI 10.1007/s11060-009-9916-2

Glioblastoma is the most common and aggressive form of primary brain tumor. The prognosis for patients diagnosed with glioblastoma is poor, with a median survival of 12–14 months and a 5-year survival rate of <5%. The upfront standard treatment for patients with newly diagnosed glioblastoma, consisting of surgery followed by chemotherapy combined with radiotherapy, provides only short-term survival benefits. Recurrent glioblastoma is an extremely challenging therapeutic setting because of the aggressive and resistant nature of the tumor. A set of key molecular targets in oncology is the Src family of non-receptor protein kinases. Dysregulated signaling via the Src kinases has been shown to underlie glioma-related proliferation, angiogenesis, migration, and survival. Here we review the biologic role of Src in malignant glioma and discuss key preclinical studies demonstrating the potential utility of inhibiting Src in glioma. Proof of clinical benefit is forthcoming from the first clinical studies involving the newest generation of small molecule Src inhibitors currently in clinical trials for recurrent glioblastoma. Blocking Src alone will likely not translate into a significant clinical benefit; thus, strategies for combining Src inhibitors with potential synergistic therapeutic modalities will be discussed. This review focus on dasatinib, the most advanced Src inhibitor being tested in glioblastoma, which is currently in phase I/II trials in this setting.


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Foramen magnum meningiomas: experiences in 114 patients

Surgical Neurology 72 (2009) 376–382. doi:10.1016/j.surneu.2009.05.006

Background: Although there has been great development in the anatomical understanding and operative techniques for skull base tumors, controversy still exists regarding the optimal surgical strategies for the FMMs. We report clinical and radiologic features as well as the surgical findings and outcome for patients with FMM treated at our institution over the last 15 years.
Methods: We reviewed 114 consecutive cases of FMM operated between May 1993 and June 2008 in the neurosurgery department at Beijing Tiantan Hospital.
Results: There were 68 female and 46 male patients (mean age, 52.3 years; range, 28-76 years). Foramen magnum meningiomas were classified as anterior (80 cases), anterolateral (24 cases), and posterolateral (10 cases). Mean duration of symptoms was 11.7 months (ranging from 1.5 to 240 months). Cervico-occipital pain (80.7%) and headache and dizziness (42.1%) were the most common presenting symptoms. The preoperative KPS was 72.5 ± 8.3. Mean maximum diameter of the tumors on MRI was 3.35 cm (range, 1.5-4.7 cm). Posterior midline approach was performed in 10 cases, far-lateral retrocondylar approach in 97 cases, and extended far-lateral approach in 7 cases. Gross total resection was achieved in 86.0% of patients and subtotal resection in 14.0%. Surgical mortality was 1.8%. Follow-up data were available for 93 patients, with a mean follow-up of 90.3 months (range, 1-180 months), of which 59 (63.4%) lived a normal life (KPS, 80-100).
Conclusion: Our experience suggests that most anterior and anterolateral FMMs can be completely resected by a far-lateral retrocondylar approach without resection of the occipital condyle. Complete resection of the tumor should be attempted at the first operation. Postoperative management of FMM is important for the prognosis.

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Radiologically documented adjacent-segment degeneration after cervical arthroplasty

Surgical Neurology 72 (2009) 325–329. doi:10.1016/j.surneu.2009.02.013

Background: The authors retrospectively studied the incidence and characteristics of radiologically documented adjacent-segment degeneration after single-level diskectomy and subsequent cervical arthroplasty using the Bryan (Medtronic Sofamor Danek; Memphis, TN) disk prosthesis.

Methods: Seventy-two patients with single-level arthroplasty using the Bryan cervical disk prosthesis were evaluated. Radiological evidence of adjacent-disk disease included new formation or enlargement of anterior osteophyte, new or increasing ALL calcification, or narrowing of disk space documented on serial plain radiographs. We reported the characteristics of adjacent-segment degeneration and reviewed all of the cases.

Results: Among the 72 patients, 9 patients (12.5%) showed radiological evidence of adjacentsegment degeneration. The mean age was 43.3 years old, with a male-female ratio 1:3. The mean follow-up period was 24.2 (12.1-35.9) months. The mean period of onset was 16.3 months. Uppersegment degeneration was documented in 4 cases (3 new osteophyte, 1 enlargement of osteophyte), whereas lower-segment degeneration was noted in 5 cases (1 new osteophyte, 3 enlargement of osteophyte, 1 decreased disk height). Among the degenerated cases, 4 cases (44.4%) also showed various degrees of HO.

Conclusions: The rate of adjacent-segment degeneration was higher than that observed in previous studies. Adjacent-segment degeneration documented a tendency toward HO. A longer follow-up period is necessary to investigate and document the different types of degeneration seen at levels adjacent to artificial Bryan cervical disk prostheses.

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Indications for Brain Computed Tomography and Hospital Admission in Pediatric Patients with Minor Head Injury

Pediatr Neurosurg 2009;45:262–270. DOI: 10.1159/000228984

Objectives: The aim of this study was to describe the characteristics of patients with a minor head injury (MHI) who were admitted to a pediatric emergency unit and to identify the clinical signs and symptoms that most reliably predict the need for cranial computed tomography (CCT) and hospital admission following MHI.

Methods: All patients were retrospectively evaluated according to age, gender, details of injury, presenting symptoms, physical examination findings, radiological investigations ordered and results, length of stay, outcome of the injury and hospitalization rates.

Results:The factors affecting indications for computed tomography and hospitalization were retrospectively analyzed in 916 patients – 585 males and 331 females, aged between 1month and 15 years (mean: 5.01 8 3.58 years), with MHI. A multivariate analysis revealed significant correlations between CCT abnormalities and Glasgow Coma Scale scores of 13 or 14, headache, posttraumatic amnesia, blurred vision, cephalohematomas, periorbital ecchymoses, otorrhea and abnormal neurological findings. CCT abnormalities were identified in 67 (19.8%) of the 338 CCT scans. Twenty of the 67 patients (29.9%) with CCT scan abnormality had no clinical signs. Of all cases, 125 (13.6%) were hospitalized, 617 (67.4%) were treated as outpatients, and 174 (19.0%) left the emergency department based on a personal decision.

Conclusion: Some clinical risk factors can be used as predictors of abnormalities in CCT scans following MHI, but the absence of such clinical findings does not exclude the possibility of intracranial injuries.

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Risk of stereotactic biopsy in eloquent brain regions

J Neurosurg 111:820–824, 2009. DOI: 10.3171/2009.3.JNS081695

Object. Frameless stereotactic biopsy has been shown in multiple studies to be a safe and effective tool for the diagnosis of brain lesions. However, no study has directly evaluated its safety in lesions located in eloquent regions in comparison with noneloquent locations. In this study, the authors determine whether an increased risk of neurological decline is associated with biopsy of lesions in eloquent regions of the brain.
Methods. Medical records, including imaging studies, were reviewed for 284 cases in which frameless stereotactic biopsy procedures were performed by 19 neurosurgeons at 7 institutions between January 2000 and December 2006. Lesion location was classified as eloquent or noneloquent in each patient. The incidence of neurological decline was calculated for each group.
Results. During the study period, 160 of the 284 biopsies predominately involved eloquent regions of the brain. In evaluation of the complication rate with respect to biopsy site, neurological decline occurred in 9 (5.6%) of 160 biopsies in eloquent brain areas and 10 (8.1%) of 124 biopsies in noneloquent regions; this difference was not statistically significant (p = 0.416). A higher number of needle passes was associated with the presence of a postoperative hemorrhage at the biopsy site, although not with a change in the result of neurological examination.
Conclusions. Frameless stereotactic biopsy of lesions located in eloquent brain regions is as safe and effective as biopsy of lesions in noneloquent regions. Therefore, with careful planning, frameless stereotactic biopsy remains a valuable and safe tool for diagnosis of brain lesions, independent of lesion location.

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