摘要:

THIS ARTICLE DISCUSSES the presentation, natural history, and management of arteriovenous malformations (AVMs) in elderly patients, based on our experience at the Dartmouth-Hitchcock Medical Center. We also present a review of the literature. In our series of 50 patients with AVMs who were operated on by one surgeon, six patients were 65 years old or older at the time of presentation. All six patients presented with intracerebral hemorrhage, and one patient had developed a seizure disorder 2 months before hemorrhaging. In three patients, the clinical course was consistent with the occurrence of two hemorrhages within a 48-hour period. The patients' preoperative neurological status varied from intact to moribund. In two patients, the diagnosis of AVM was made intraoperatively. Preoperative angiography revealed the diagnosis in the remaining patients. All the patients underwent surgical excision of their AVMs. Despite concurrent medical illnesses, all patients tolerated the procedure well with no new, persistent neurological deficits. At follow-up, all patients showed sufficient neurological recovery to return to the community and four of the patients were neurologically intact. Based on this experience and a review of the literature, we conclude that AVMs in elderly patients are not benign lesions and that surgical excision should be considered among the management options for these patients.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

BECAUSE CONVENTIONAL STEREOTACTIC angiography provides only two-dimensional information for dose planning, we studied the accuracy and usefulness of stereotactic magnetic resonance angiography (sMRA) for arteriovenous malformation (AVM) radiosurgery in 28 consecutive patients. We hypothesized that the multidimensional data set provided by sMRA and the opportunity to image both blood vessels and brain parenchyma would improve the accuracy of AVM irradiation and improve the safety of radiosurgery. Twenty-eight patients with AVMs in different brain locations and with a variety of AVM sizes (range, 15–31 mm mean diameter) had sMRA followed by stereotactic angiography. The sMRA images only were used to construct an initial radiosurgical plan. This plan was then used to outline the AVM volume defined by conventional angiography. In 24 patients, sMRA information equaled that of conventional angiography. In 3 patients, sMRA was better, because conventional angiography overestimated the size of the AVM nidus. In one patient, the conventional angiogram showed a second separate nidus (10-mm diameter) that was not as well defined on MRA. There were no complications with any procedure. In 16 patients (57%), sMRA provided critical information on AVM shape that was not provided by conventional angiography alone. Stereotactic MRA is a fast, noninvasive, inexpensive, multidimensional imaging method for AVM radiosurgery that provides information on vascular and parenchymal brain anatomy important for optimal dose planning. We believe that it can be used with confidence as the sole imaging method for medium-size, compact-nidus AVMs.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

THE PURPOSE OF this study was to investigate the relationship between mild degrees of liver dysfunction and spontaneous intracerebral hemorrhage (ICH) from the hemostatic standpoint. A detailed study of hemostatic systems was made in 462 patients with ICH. To compare ICH with the other cerebrovascular diseases, data from 120 patients with subarachnoid hemorrhage and 114 others with cerebral infarction were reviewed. At admission, the medical histories of the patients, including information about previous alcohol consumption, was taken, and blood samples were collected to perform the following studies: platelet count, fibrinogen level, prothrombin time, activated partial thromboplastin time, antithrombin III, plasminogen and α2-antiplasmin activity, platelet aggregability, and liver function tests. The incidence of liver dysfunction and alcohol consumption in patients with ICH was significantly (P< 0.05) higher than in patients with subarachnoid hemorrhage and in those with cerebral infarction. Hematoma volume, mortality rate, and past alcohol consumption in patients with ICH significantly increased with worsening severity of liver dysfunction. Although almost all hemostatic parameters became worse with increasing severity of liver dysfunction, they changed within the normal limits. Platelet aggregability and α2-antiplasmin activity in patients with liver dysfunction were remarkably deteriorated beyond normal limits. In conclusion, liver dysfunction associated with alcohol consumption appears to be an important factor in the deterioration of the clinical status of patients with ICH and may be one of the causative factors in the development of ICH. Although mildly impaired hemostatic systems may be partially responsible for these adverse effects of liver dysfunction on ICH, it seems probable that nonhemostatic mechanisms are attributed to the effects.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

THE RESULTS OF a Phase II clinical trial of intrathecal recombinant tissue-type plasminogen activator for the prevention of vasospasm were reported. The subjects were 53 patients with aneurysmal subarachnoid hemorrhage (SAH), Groups 2 to 4 in Fisher's preoperative computed tomography classification and Grades II to IV in the Hunt-Kosnik classification. Twenty-four hours after surgery, tissue-type plasminogen activator (TD-2061) was intracisternally administered via a catheter (0.1, 0.2, or 0.4 mg, three times daily for 5 days). The clot-dissolving effects assessed as “effective” and “markedly effective” were virtually the same in the 0.1- and 0.2-mg groups (66.7% and 64.3%, respectively) but slightly lower (53.3%) in the 0.4-mg group, suggesting an adequate effect in the 0.1- and 0.2-mg groups. Severe angiographic vasospasm was not observed in any of three groups. No intergroup differences were noted in the incidence of symptomatic vasospasm, low density on computed tomography 1 month after SAH, and functional prognosis. Bleeding complications were noted in 4 patients (7.5%), including 1 case of SAH in the low 0.1-mg group, 2 cases of SAH in the 0.2-mg group, and 1 case of epidural hematoma in the 0.4-mg group. In overall safety rating, 3 cases with increased SAH and 1 case of epidural hematoma were assessed as “safety doubtful.” Other minor side effects such as headache and hepatic dysfunction attributed to the effect of other simultaneously used drugs were assessed as “almost safe,” and the rate of “almost safe” and “better” for all dose groups was about 90%, suggesting a safe dose level for all groups. These results suggest that repeated intrathecal administration of tissue-type plasminogen activator is useful for preventing vasospasm even in the low dose of 0.1 mg.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

THE ABILITY OF proton magnetic resonance spectroscopy (1H MRS) to diagnose brain tumors was investigated using in vitro high-resolution spectra. Fifty-eight surgically excised samples of brain tumors (12 glioblastomas, 4 anaplastic astrocytomas, 6 astrocytomas, 12 meningiomas, 6 neurinomas, 4 chordomas, 3 craniopharyngiomas, 2 pituitary adenomas, 2 malignant lymphomas, 1 ependymoma, 1 medulloblastoma, and metastatic brain tumors including 3 pulmonary adenocarcinomas, a hepatocellular carcinoma, and a renal cell carcinoma) and 4 nontumorous lobectomized brains were examined by in vitro1H MRS.N-Acetyl-aspartate was demonstrated in normal tissues but could not be detected in nonneuroectodermal tumors. Total creatine was decreased in all brain tumors in comparison with normal brain tissues, but was relatively higher in neuroectodermal tumors than in other brain tumors. Choline-containing compounds were present in all tumors except craniopharyngioma, and their concentrations were particularly high in a metastatic brain tumor from hepatocellular carcinoma. The concentration of glycine was high in neuroectodermal tumors, whereas that of taurine was high in medulloblastoma, pituitary adenoma, and renal cell carcinoma. Alanine was increased in meningioma, glioma, and pituitary adenoma. Neurinoma had the largest inositol content among the tumors examined. Thus each type of brain tumor exhibited a characteristic MR spectrum. These data suggested that in vivo1H MRS might provide clinically useful information about tumor metabolism and aid in the differential diagnosis of tumors. Although excellent anatomical localization of tumors can be readily obtained by MR imaging, MRS may provide additional information in cases in which the differential diagnosis of tumors by MR imaging is difficult.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

NINE GERMINOMA PATIENTS are described who developed a recurrence after a complete response to radiation without adjuvant chemotherapy. Extraembryonic tumors producing α-fetoprotein and human chorionic gonadotropin were excluded from this study. Four patterns of recurrence are described with respect to mechanism and appropriate treatment. Type I germinoma recurrence, characterized by intracranial recurrence caused by an inadequate initial irradiation field was treated by total craniospinal irradiation. Type II recurrence, characterized by a benign teratoma caused by late growth of the teratoma component was treated by surgery alone. All patients with these patterns of recurrence are still alive. Type III local recurrence is characterized by human chorionic gonadotropin- or α-fetoprotein-producing tumors of extraembryonic origin. This pattern of recurrence should be treated by chemotherapy or radiosurgery, because all these patients died. Type IV germinoma recurrence consists of extraneural metastasis without evidence of intracranial recurrence. Two of these patients were treated with chemotherapy. In summary, four patients died after recurrence, whereas the remaining five patients survived. The classification of germinoma recurrence patterns should facilitate the selection of the most appropriate treatment. However, it has been difficult to identify the precise histopathology by biopsy or partial resection alone. Furthermore, chemotherapy is indicated in treating germinomas that have a ventriculoperitoneal shunt because of the risk of extraneural metastases.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

THE SUCCESSFUL MANAGEMENT of nocardial brain abscess remains problematic. The authors report 11 cases of nocardial brain abscess treated between 1971 and 1993 and review 120 cases reported since 1950. The clinical findings included focal deficits in 55 patients (42%), nonfocal findings in 36 (27%), and seizures in 39 (30%). Extraneural nocardiae were present in 66% of the cases; pulmonary (38%) and cutaneous/subcutaneous (20%) locations were the most frequent. The abscesses were single in 54% of the patients, multiple in 38%, and of unknown number in 8%. Forty-four of 131 patients (34%) were immunocompromised; since 1975, 18 of 40 immunocompromised patients (45%) were transplant recipients and six (15%) had human immunodeficiency virus. The mortality rate was 24% after initial craniotomy and excision (11/45), 50% after aspiration/drainage (17/34), and 30% after nonoperative therapy (7/23); 29 cases (22%) were diagnosed at autopsy. The mortality rate was 33% in patients with single abscesses and 66% in those with multiple abscesses (P< 0.0003). There was no difference in the mortality rates of immunocompromised and nonimmunocompromised patients treated before computed tomography (CT) was available; since the advent of CT, however, the mortality rate has been significantly higher in immunocompromised patients (55% vs. 20%,P< 0.05). Although the mortality rate for nocardial brain abscesses has dropped almost 50% since the advent of CT, it has remained virtually unchanged in immunocompromised patients and is three times higher than that of other bacterial brain abscesses (30% vs. 10%). The authors recommend image-directed stereotactic aspiration for diagnosis; however, craniotomy and total excision are necessary in most cases, because nocardial abscesses are usually multiloculated. Patients with minimal neurological deficits or small abscesses may be treated initially with antibiotics alone. Sulfonamides, alone or in combination with trimethoprim, are most effective and should be continued for at least 1 year. Minocycline, imipenem, or aminoglycoside in combination with a third-generation cephalosporin may be used with reasonably good success as second-line agents in cases of allergy or nonresponsiveness to sulfa agents.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

WE INVESTIGATED THE relationship between radiological findings and the nature of the cyst fluid and histological findings of six Rathke's cleft cysts. The results show that the majority (five of six cases) of symptomatic Rathke's cleft cysts exhibit no enlargement of the sella turcica on plain x-rays, which may be helpful in differentiating cystic pituitary adenoma in the radiological diagnostic process. Three cases with large cysts showing high-intensity T1-weighted magnetic resonance images harbored abundances of cholesterol crystal and hemosiderin pigment in the cyst walls. The high signal intensity in magnetic resonance images of Rathke's cleft cysts may be explained by hemorrhage and a deposition of cholesterol crystal and may be considered in certain cases of Rathke's cleft cyst, especially when they are large.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

ALTHOUGH GENERALLY BENIGN tumors, meningiomas may be associated with extensive peritumoral brain edema as seen on computed tomographic scans. Fifty-two patients with intracranial meningiomas were studied, and the hypodense areas on computed tomographic scans were related to the intraoperative microsurgical findings and to the sizes of the tumors. We have identified three kinds of tumor-brain interfaces characterized by different difficulties in microsurgical dissection: smooth type, transitional type, and invasive type. These different microsurgical interfaces seem to correlate very precisely with computed tomographic images of halo-like and finger-like hypodense areas, allowing prediction of the microsurgical effort to be made in the surgery of meningiomas. The size of the tumor seems to be important in our subjects in determining the amount of edema produced. Indeed, a positive correlation (P< 0.001) was found between the sizes of the tumors and the extent of peritumoral hypodensity. A positive correlation (P< 0.002) also has been found between grade of edema and cortical penetration. Cerebral cortex disruption was systematically observed by us in invasive-type meningiomas and in 3 of 21 cases (14.3%) in transitional-type meningiomas. No penetration was observed in smooth-type meningiomas.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

MOST SHUNT-DEPENDENT HYDROCEPHALIC patients present with predictable symptoms of headache and mental status changes when their cerebrospinal fluid shunts malfunction. Their intracranial pressure (ICP) is usually high, and they usually respond to routine shunt revision. This report describes 12 shunted patients who were admitted with the full-blown hydrocephalic syndrome but with low to low-normal ICP. All 12 patients had been maintained previously on medium-pressure shunts. Their symptoms included headache, lethargy, obtundation, and cranial neuropathies. At peak symptoms, their ventricular sizes were large (ventricular/biparietal ratio of 0.35 to 0.45) in six and massive (ventricular/biparietal ratio >0.45) in six and their ICPs ranged from 2.2 to 6.6 mm Hg, with a mean of 4.4 ± 1.3 mm Hg (±standard deviation), i.e., below or well within the pressure range of their shunts. The pressure volume index of three patients at peak symptoms ranged from 39.2 to 48.5 ml, with a mean of 43.9 ± 4.6 ml, which represents a 190% increase from the predicted normal value. Seven patients failed to improve with multiple shunt revisions, including the use of low-pressure valves. In 11 patients, symptoms and ventriculomegaly were not reversed except with prolonged external ventricular drainage at subzero pressures (mean external ventricular drainage nadir pressure of −5.7 ± 3.6 mm Hg, for a mean period of 22.2 days). During external ventricular drainage treatment, symptoms correlated only with ventricular size and not with ICP. All 11 were subsequently treated successfully with a new medium- or low-pressure shunt. One patient was treated successfully with prolonged shunt pumping. We postulate that: 1) the development of this low-pressure hydrocephalic state is related to alteration of the viscoelastic modulus of the brain, secondary to expulsion of extracellular water from the brain parenchyma, and to structural changes in brain tissues due to prolonged overstretching; 2) certain patients are susceptible to developing low-pressure hydrocephalic state because of an innate low brain elasticity due to bioatrophic changes; 3) low-pressure hydrocephalic state symptoms are due not to pressure changes but to brain tissue distortion and cortical ischemia secondary to severe ventricular distortion and elevated radial compressive stresses within the brain; and 4) treatment must be directed toward allowing the entry of water into the brain parenchyma and the restoration of baseline brain viscoelasticity.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID