摘要:

OBJECTIVEMicrovascular decompression (MVD) is associated with low mortality and morbidity rates at specialized centers, but many MVD procedures are performed outside such centers. We studied short-term end points after MVD in a national hospital discharge database sample.METHODSA retrospective cohort study was performed by using the Nationwide Inpatient Sample, 1996 to 2000.RESULTSThe sample included 1326 MVD procedures for treatment of trigeminal neuralgia, 237 for treatment of hemifacial spasm, and 27 for treatment of glossopharyngeal neuralgia, performed at 305 hospitals by 277 identified surgeons. The mortality rate was 0.3%, and the rate of discharge other than to home was 3.8%. Neurological complications were coded in 1.7% of cases, hematomas in 0.5%, and facial palsies in 0.6%, with 0.4% of patients requiring ventriculostomies and 0.7% postoperative ventilation. Trigeminal nerve section was also coded for 3.4% of patients with trigeminal neuralgia, more commonly among older patients (P= 0.08), among female patients (P= 0.03), and at teaching hospitals (P= 0.02). The median annual caseloads were 5 cases per hospital (range, 1–195 cases) and 3 cases per surgeon (range, 1–107 cases). With adjustment for age, sex, race, primary insurance, diagnosis (trigeminal neuralgia versus hemifacial spasm versus glossopharyngeal neuralgia), geographic region, admission type and source, and medical comorbidities, outcomes at discharge were superior at higher-volume hospitals (P= 0.006) and with higher-volume surgeons (P= 0.02). Complications were less frequent after surgery performed at high-volume hospitals (P= 0.04) or by high-volume surgeons (P= 0.01). The rate of discharge other than to home was 5.1% for the lowest-volume-quartile hospitals, compared with 1.6% for the highest-volume-quartile hospitals. Volume and mortality rate were not significantly related, but three of the four deaths in the series followed procedures performed by surgeons who had performed only one MVD procedure that year. Length of stay (median, 3 d) and hospital volume were not significantly related. Hospital charges were slightly higher at higher-volume hospitals (P= 0.007).CONCLUSIONAlthough most MVD procedures in the United States are performed at low-volume centers, mortality rates remain low. Morbidity rates are significantly lower at high-volume hospitals and with high-volume surgeons.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVEBecause of the irreversibility of lesioning procedures and their possible side effects, we studied the efficacy of replacing bilateral anterior capsulotomy with chronic electrical capsular stimulation in patients with severe, long-standing, treatment-resistant obsessive-compulsive disorder.METHODSWe stereotactically implanted quadripolar electrodes in both anterior limbs of the internal capsules into six patients with severe obsessive-compulsive disorder. Psychiatrists and psychologists performed a double-blind clinical assessment. A blinded random crossover design was used to assess four of those patients, who underwent continuous stimulation thereafter.RESULTSThe psychiatrist-rated Yale-Brown Obsessive Compulsive Scale score was lower in the stimulation-on condition (mean, 19.8 ± 8.0) than in the postoperative stimulator-off condition (mean, 32.3 ± 3.9), and this stimulation-induced effect was maintained for at least 21 months after surgery. The Clinical Global Severity score decreased from 5 (severe; standard deviation, 0) in the stimulation-off condition to 3.3 (moderate to moderate-severe; standard deviation, 0.96) in the stimulation-on condition. The Clinical Global Improvement scores were unchanged in one patient and much improved in the other three during stimulation. During the stimulation-off period, symptom severity approached baseline levels in the four patients. Bilateral stimulation led to increased signal on functional magnetic resonance imaging studies, especially in the pons. Digital subtraction analysis of preoperative [18F]2-fluoro-2-deoxy-d-glucose positron emission tomographic scans and positron emission tomographic scans obtained after 3 months of stimulation showed decreased frontal metabolism during stimulation.CONCLUSIONThese observations indicate that capsular stimulation reduces core symptoms 21 months after surgery in patients with severe, long-standing, treatment-refractory obsessive-compulsive disorder. The stimulation elicited changes in regional brain activity as measured by functional magnetic resonance imaging and positron emission tomography.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVEOne concern with respect to stent procedures performed to treat patients with intracranial lesions is the fate of normal major arterial branches after stents are placed across them. Because most of these lesions occur at vessel bifurcations or at branch points, a normal major branch often arises near the lesion and may be difficult to avoid during stent positioning. The aim of this article is to describe the angiographic outcome of intracranial major branch arteries crossed by a stent in the intracranial circulation.METHODSWe examined the immediate postprocedural cerebral angiograms of the 40 patients who underwent intracranial stenting at the University at Buffalo, Buffalo, NY, between June 1998 and April 2000. In each of 10 patients, the stent was placed across a normal major branch artery. Stents were used to treat aneurysms in seven patients and intracranial stenosis in three patients. The latest cerebral angiogram available was reviewed, and the patency of the major branch arteries was evaluated.RESULTSThe angiographic follow-up period ranged from 4 days to 35 months (mean follow-up, 10 mo). Each of the 10 major branch arteries was patent. No infarcts were associated with the territory of the major branch arteries crossed by the stents, and no patient experienced a related episode of clinical ischemia. Four patients died as a result of causes unrelated to the stenting procedure. The histology of a middle cerebral artery stent that was placed across a lenticulostriate perforator is presented.CONCLUSIONThe flexible, low-profile stents used in this study had no angiographically or clinically apparent effect on the major intracranial branches across which they were placed.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVERecent reports in the literature have described a significant discrepancy in adverse outcomes between coil embolization (CE; 10%) and surgical clipping (SC; 25%) for the management of unruptured intracranial aneurysms (UIA). This discrepancy led us to analyze our experience.METHODSIn 1996, we designed a prospective study of patients with UIA in which CE was considered the treatment of choice and was performed if the interventional neuroradiologists deemed the aneurysm’s fundus-to-neck ratio accessible for CE. SC was performed only if complete CE was unlikely to be achieved or in patients in whom CE already had failed.RESULTSCE was performed in 38 patients with at least one UIA (41 UIAs, 83% in the anterior circulation). SC was performed in 39 patients with at least one UIA unsuitable for CE (59 UIAs, including 6 after failed CE, 96.5% in the anterior circulation). For CE, the total obliteration rate was 56.1%, the subtotal was 14.6%, and CE failed in 29.3%. There were transient complications in 10% of the cases and permanent complications in 7.5%. Of the 12 failed CE procedures, 7 (58%) were performed for middle cerebral artery aneurysms. For SC, the total obliteration rate was 93.2%, the subtotal was 1.7%, and SC failed (wrapping) in 5.1%. There were transient complications in 16.3% of the patients and permanent complications in 1.7%. The success rate for CE was similar to that for SC only when CE was used for aneurysms with a fundus-to-neck ratio of at least 2.5.CONCLUSIONSC can produce better results than CE in patients with UIA of the anterior circulation. CE as a first-line treatment should be reserved for patients with UIAs with a fundus-to-neck ratio of 2.5 or greater.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVERadiosurgery is commonly performed for patients with small to medium-sized arteriovenous malformations (AVMs). However, few articles present overall outcomes after one or more radiosurgical procedures, and few data are available for periods longer than 5 years after AVM radiosurgery.METHODSBetween 1990 and 1997, 144 patients underwent AVM radiosurgery and had angiographic follow-up. Of these patients, 112 (78%) had Spetzler-Martin Grade III or greater AVMs; 37 (26%) were located in the basal ganglia, thalamus, or brainstem. Twenty-six patients (18%) underwent repeat radiosurgery. The mean follow-up of 15 patients who died as a result of AVM bleeding or underwent AVM resection after the initial radiosurgery was 22 months (range, 3–47 mo); the mean follow-up of the remaining 129 patients was 86 months (range, 23–169 mo).RESULTSExcellent (obliteration without deficit, n = 96) or good (obliteration with minor deficit, n = 9) outcomes were achieved in 73% of patients after one or more radiosurgical procedures. Twenty patients (14%) sustained major deficits (n = 15; five had obliteration) or died (n = 5) after radiosurgery. Sixteen patients (11%) had unchanged neurological examinations but persistent arteriovenous shunting. Five patients (4%) required surgery (cystoperitoneal shunting, n = 1; AVM resection, n = 4) at a median of 65 months after radiosurgery because of symptomatic cyst formation or persistent edema. The radiosurgery AVM score correlated with both excellent (R2= −0.93,P= 0.003) and excellent or good (R2= −0.92,P= 0.004) outcomes.CONCLUSIONThe majority of AVM patients are protected from the risk of future hemorrhage and continue their normal daily activities after radiosurgery. Late complications requiring treatment are rare but can occur many years after patients are considered cured of their AVMs. Overall outcomes after AVM radiosurgery seem to be predicted accurately by the described method.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVEBoth cortical oxygen saturation (SaO2) and cortical blood volume (BV) are related to regional cerebral blood flow. Among a series of patients with cerebral arteriovenous malformations, we examined the problem of hyperemia after embolization/resection or resection with the intraoperative application of near-infrared spectroscopy.METHODSCortical SaO2and BV (intracapillary total hemoglobin concentrations) were measured, with near-infrared spectroscopy, in areas adjacent to the arteriovenous malformation for 20 patients, before and after resection. The absolute values for both parameters and postexcision/preexcision ratios (P-P ratios) were determined. Data were correlated with multiple clinical and preoperative angiographic parameters.RESULTSBefore resection, the mean SaO2was 49 ± 16% and the mean BV was 12.65 ± 7.41 mg/ml. After resection, SaO2increased for 17 of 20 patients and BV increased for 18 of 20 patients. The differences between pre- and postexcision values for both parameters were observed to be statistically significant (P< 0.01). The average P-P ratios were 1.5 ± 0.4 for SaO2and 1.7 ± 0.4 for BV. Correlation between the P-P ratios for the two parameters was good. The initial BV and the P-P ratios for both SaO2and BV were exclusively dependent on the extent of preoperative embolization. Postoperatively, two patients developed intracerebral hemorrhage or severe edema. Both demonstrated high P-P ratios for SaO2(2.3 and 2.1) and BV (1.6 and 2.1).CONCLUSIONIntraoperative near-infrared spectroscopy is able to detect the hyperemic status of adjacent cortex after arteriovenous malformation resection. However, staged therapy with embolization and surgery results in less hyperemia after resection. While two patients with hyperemic complications exhibited very large increases in SaO2and BV, we cannot refute the normal-perfusion pressure breakthrough theory.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVEChanges of major cerebral vessels in patients with subarachnoid hemorrhage (SAH) are well known from routine cerebral angiography. Data on changes in the microcirculation do not exist. This study sought to provide a qualitative and quantitative analysis of the cortical microcirculation after SAH.METHODSBy means of orthogonal polarization spectral imaging, a qualitative and quantitative analysis of cortical microcirculation was performed during aneurysm surgery in 3 patients with an incidental intracerebral aneurysm and 10 patients with SAH. Vessel diameters, red blood cell velocity, and functional capillary density were analyzed before and after the aneurysm was clipped.RESULTSInitial capillary density in patients with an incidental aneurysm was 91.5 ± 36.5 cm−1(mean ± standard deviation) compared with 30.5 ± 13.8 in patients with SAH (P< 0.05). In patients with SAH, capillary density increased significantly to 53.9 ± 29.1 cm−1(P< 0.05) during the operation, as did the frequency of venules with a red blood cell velocity greater than 2 mm/s (P< 0.05). No significant change of arteriolar or venular diameters was observed. However, in patients with SAH, mono- and multisegmental microvasospasms in arterioles were observed, with a reduction of vessel diameters up to 75.1%.CONCLUSIONOrthogonal polarization spectral imaging is a suitable method to study cerebral microcirculation during surgery. In patients with SAH, capillary density is significantly decreased and small arteries and arterioles of the cortical surface exhibit vasospasm that cannot be detected by angiography or transcranial Doppler sonography. These changes may contribute to the initial clinical symptoms and may have an influence on the clinical postoperative course.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVEWhole brain radiotherapy (WBRT) provides benefit for patients with brain metastases but may result in neurological toxicity for patients with extended survival times. Stereotactic radiosurgery in combination with WBRT has become an important approach, but the value of WBRT has been questioned. As an alternative to WBRT, we managed patients with stereotactic radiosurgery alone, evaluated patients’ outcomes, and assessed prognostic factors for survival and tumor control.METHODSOne hundred seventy-two patients with brain metastases were managed with radiosurgery alone. One hundred twenty-one patients were evaluable with follow-up imaging after radiosurgery. The median patient age was 60.5 years (age range, 16–86 yr). The mean marginal tumor dose and volume were 18.5 Gy (range, 11–22 Gy) and 4.4 ml (range, 0.1–24.9 ml). Eighty percent of patients had solitary tumors.RESULTSThe overall median survival time was 8 months. The median survival time in patients with no evidence of primary tumor disease or stable disease was 13 and 11 months. The local tumor control rate was 87%. At 2 years, the rate of local control, remote brain control, and total intracranial control were 75, 41, and 27%, respectively. In multivariate analysis, advanced primary tumor status (P= 0.0003), older age (P= 0.008), lower Karnofsky Performance Scale score (P= 0.01), and malignant melanoma (P= 0.005) were significant for poorer survival. The median survival time was 28 months for patients younger than 60 years of age, with Karnofsky Performance Scale score of at least 90, and whose primary tumor status showed either no evidence of disease or stable disease. Tumor volume (P= 0.02) alone was significant for local tumor control, whereas no factor affected remote or intracranial tumor control. Eleven patients developed complications, six of which were persistent. Nineteen (16.5%) of 116 patients in whom the cause of death was obtained died as a result of causes related to brain metastasis.CONCLUSIONBrain metastases were controlled well with radiosurgery alone as initial therapy. We advocate that WBRT should not be part of the initial treatment protocol for selected patients with one or two tumors with good control of their primary cancer, better Karnofsky Performance Scale score, and younger age, all of which are predictors of longer survival.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVEThe objective of this study was to determine the nationwide, population-based incidences of intracranial gliomas and meningiomas (of all grades) during 55 years of monitoring in Denmark.METHODSOn the basis of reports in the Danish Cancer Registry, we calculated age-standardized, period-specific incidences and age- and birth cohort-specific incidences, in 5-year age and calendar intervals, for intracranial gliomas and meningiomas.RESULTSThe incidence of gliomas increased 1.7-fold from 1943 to 1947 to 1993 to 1997, whereas the incidence for meningiomas increased 3.9-fold during the same period.CONCLUSIONBased on complete notification to the Danish Cancer Registry, the overall incidences of intracranial gliomas and meningiomas increased during a 55-year period. These increases were observed for all age groups and both sexes. These increases could be explained on the basis of improved diagnoses of these tumors. For gliomas, a maximal annual incidence of approximately 4 cases/100,000 population (World Standard Population) was observed in Denmark at the end of the study period, suggesting that the effects of improved diagnostic tools have reached their maximum with respect to this tumor type. The same was not observed for the incidence of meningiomas, suggesting that perhaps underreporting is still present.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVEThe aim of this study was to analyze the usefulness of preoperative language functional magnetic resonance imaging (fMRI), by correlating fMRI data with intraoperative cortical stimulation results for patients with brain tumors.METHODSNaming and verb generation tasks were used, separately or in combination, for 14 right-handed patients with tumors in the left hemisphere. fMRI data obtained were analyzed with SPM software, with two standard analysis thresholds (P< 0.005 and thenP< 0.05). The fMRI data were then registered in a frameless stereotactic neuronavigational device and correlated with direct brain mapping results. We used a statistical model with the fMRI information as a predictor, spatially correlating each intraoperatively mapped cortical site with fMRI data integrated in the neuronavigational system (site-by-site correlation). Eight patients were also studied with language fMRI postoperatively, with the same acquisition protocol.RESULTSWe observed high variability in signal extents and locations among patients with both tasks. The activated areas were located mainly in the left hemisphere in the middle and inferior frontal gyri (F2 and F3), the superior and middle temporal gyri (T1 and T2), and the supramarginal and angular gyri. A total of 426 cortical sites were tested for each task among the 14 patients. In frontal and temporoparietal areas, poor sensitivity of the fMRI technique was observed for the naming and verb generation tasks (22 and 36%, respectively) withP< 0.005 as the analysis threshold. Although not perfect, the specificity of the fMRI technique was good in all conditions (97% for the naming task and 98% for the verb generation task). Better correlation (sensitivity, 59%; specificity, 97%) was achieved by combining the two fMRI tasks. Variation of the analysis threshold toP< 0.05 increased the sensitivity to 66% while decreasing the specificity to 91%. Postoperative fMRI data (for the cortical brain areas studied intraoperatively) were in accordance with brain mapping results for six of eight patients. Complete agreement between pre- and postoperative fMRI studies and direct brain mapping results was observed for only three of eight patients.CONCLUSIONWith the paradigms and analysis thresholds used in this study, language fMRI data obtained with naming or verb generation tasks, before and after surgery, were imperfectly correlated with intraoperative brain mapping results. A better correlation could be obtained by combining the fMRI tasks. The overall results of this study demonstrated that language fMRI could not be used to make critical surgical decisions in the absence of direct brain mapping. Other acquisition protocols are required for evaluation of the potential role of language fMRI in the accurate detection of essential cortical language areas.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID