摘要:

IN A SERIES of 40 patients undergoing an awake craniotomy for the removal of a glioma of the dominant hemisphere temporal lobe, cortical stimulation mapping was used to localize essential language sites. These sites were localized to distinct temporal lobe sectors and compared with 83 patients without tumors who had undergone language mapping for the treatment of intractable epilepsy. In patients with and without temporal lobe gliomas, the superior temporal gyrus contained significantly more language sites than the middle temporal gyrus. Both patient populations also had language sites anterior to the central sulcus in the superior temporal gyrus (12–16%). The patients without tumors had significantly more language sites in the superior temporal gyrus, compared with the superior temporal gyrus of patients with temporal lobe tumors. Multiple variables were studied for their effect on preoperative and postoperative language deficits and included age, sex, number of language sites, histology, size of the tumor, and the distance of tumor resection margins from the nearest language site. The distance of the resection margin from the nearest language site was the most important variable in determining the improvement in preoperative language deficits, the duration of postoperative language deficits, and whether the postoperative language deficits were permanent. If the distance of the resection margin from the nearest language site was > 1 cm, significantly fewer permanent language deficits occurred. Cortical stimulation mapping for the identification of essential language sites in patients with gliomas of the dominant hemisphere temporal lobe will maximize the extent of tumor resection and minimize permanent language deficits.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

SEVENTY-ONE PATIENTS WITH supratentorial mixed oligoastrocytomas underwent surgery only (5 patients) or surgery with postoperative radiation therapy (66 patients) between 1960 and 1982. The median survival for these 71 patients was 5.8 years and the 5-, 10-, and 15-year survival rates were 55, 29, and 17%, respectively–values significantly different from those of an age- and sex-matched normal reference population. Uni- and multivariate survival analyses were applied to 14 possible prognostic factors, including the following: patient factors–age, sex, and seizures; tumor factors–site, size, side, computed tomographic enhancement, and calcification; pathological factors–tumor grade and dominant cellular component; and treatment factors–extent of surgical resection, lobectomy, and radiation dose and field. Of these factors, tumor grade, as determined by the Kernohan method, was the most strongly associated with survival. The 60 patients with Grades 1 and 2 tumors had a median survival of approximately 6.3 years and 5- and 10-year survival rates of 58% and 32%, respectively, compared with 2.8 years (36 and 9%, respectively) for the 11 patients with Grades 3 and 4 tumors. Age < 37 years, gross total resection, partial brain radiation, and radiation dose ≥ 5000 cGy were other factors significantly associated with improved survival in both uni- and multivariate models. Three of five patients not receiving postoperative radiation therapy experienced tumor recurrence and died. Seven of eight patients from whom tissue was obtained at the time of tumor progression demonstrated anaplastic transformation. In conclusion, this retrospective analysis suggests that maximum surgical resection plus postoperative radiation therapy, using partial brain treatment fields with doses ≥ 5000 cGy, appears to be associated with improved survival for patients with mixed oligoastrocytomas.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

DESMOPLASTIC INFANTILE GANGLIOGLIOMAS are massive cystic tumors, typically occurring in the cerebral hemispheres of infants. They are remarkable pathologically for a prominent desmoplasia and, in some cases, for a cellular mitotically active component that can be readily interpreted as a malignant neoplasm. Four children less than 1 year of age were diagnosed with desmoplastic infantile gangliogliomas in the Pediatric Oncology Group infant brain tumor study (Protocol number 8633). All had been diagnosed by their respective institutions as having malignant tumors, i.e., Grade III astrocytoma, malignant meningioma, leptomeningeal fibrosarcoma, and gliosarcoma. All had increased intracranial pressure, and two had seizures. The tumors were extremely large, with one measuring 12×9×9 cm. None had evidence of metastatic disease. One patient had a gross total resection, and the other three had debulking procedures. All four children were treated with chemotherapy (cyclophosphamide, vincristine, cisplatinum, etoposide) for periods ranging from 12 to 24 months. Of those with postoperative measurable disease, one child had a complete response, one a partial response, and one had stable disease at the conclusion of chemotherapy. No child received radiation therapy. All children are alive with progression-free survivals after diagnosis of more than 36, 42, 48, and 60 months, respectively. Although desmoplastic infantile gangliomas are rare, recognition of this tumor type is essential because, despite their massive size and pathologically malignant appearance, they may have a relatively benign clinical course. If total surgical resection can be achieved, further therapy may not be indicated. In those patients in whom residual disease is present, chemotherapy appears to be an effective form of therapy. With improved recognition of this entity, future reports should help clarify its biological behavior and the efficacy of various treatment regimens.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

MENINGEAL AND CORTICAL biopsies were evaluated in 37 patients (25 men and 12 women; mean age, 54 yr) who had chronic meningitis of an unknown cause between 1985 and 1993 (the era of magnetic resonance imaging). Magnetic resonance imaging with gadolinium contrast was the most useful diagnostic imaging technique, demonstrating meningeal enhancement in 15 of 32 patients (47%). Only 2 of 32 (6%) computed tomographic scans revealed enhancement. A definitive diagnosis was made in 16 of 41 biopsies (39%), but in cases where enhancement was present on either magnetic resonance imaging or computed tomography, a diagnosis was obtained in 80% (12 of 15 cases). Only 2 of 22 biopsies (9%) from nonenhancing regions were diagnostic. Although the locations of enhancement were distributed evenly, biopsies through suboccipital and pterional craniotomies gave the highest diagnostic yields (50%). Furthermore, if the biopsies were obtained from enhancing regions, the yield of these two approaches increased to 84 and 100%, respectively. Of 18 cases in which biopsy samples were taken from both the meninges and cortex, only 1 had cortical involvement alone. The meninges were therefore diagnostic in 15 of the 16 definitive diagnostic cases (94%). Second biopsies were necessary in four cases, of which the three biopsies from enhancing regions were diagnostic. The most frequent causes of chronic meningitis were sarcoid (31%) and metastatic adenocarcinoma (25%). We made the following conclusions: 1) magnetic resonance imaging is the preferred imaging technique; 2) a biopsy of an enhancing region is most likely to be diagnostic; 3) posterior fossa or pterional approaches give the highest diagnostic yield; and 4) that a cortical biopsy, although helpful for preserving the structural integrity of the overlying leptomeninges, may be unnecessary and should be individualized.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

WE HAVE PREVIOUSLY proposed the existence of the tethered cord syndrome in the presence of a conus medullaris in the normal position. Our 12-year series of 73 patients with the tethered cord syndrome included 13 patients in whom the spinal cord terminated at or above the L1-L2 disc space. We compare the characteristics of these 13 with those of the 60 patients whose spinal cord terminated below the L1-L2 disc space. The parameters for comparison included neurological status at presentation and follow-up, the presence of cutaneous stigmata of occult spinal dysraphism, vertebral anomalies, and others. The frequency of occurrence of each parameter in the normally positioned group was essentially the same as its occurrence in the low-lying group.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

WE HYPOTHESIZED THAT chronic hypotension in normal vascular territories fed by arteriovenous malformation pedicles may reset the lower limit of autoregulation and allow flow to remain constant over a lower pressure range. We studied the effect of increasing systemic mean arterial pressure (SMAP) with phenylephrine on cerebral blood flow using a novel technique. Fourteen patients undergoing 15 procedures were studied before endovascular embolization of arteriovenous malformations under neuroleptic conscious sedation. Mean pressures were transduced via a 1.5-F intracranial microcatheter, which was passed under fluoroscopic guidance into the target feeding artery. The microcatheter was positioned (unwedged) at a point that was relatively hypotensive to systemic pressure but that irrigated normal cortex on angiography; feeding mean arterial pressure (FMAP) and SMAP were recorded. A bolus of133Xe in saline was injected into the microcatheter, and washout was recorded for 3 minutes by a scintillation detector placed over the vascular territory of the injected pedicle. SMAP was then increased ≈ 25 mm Hg by phenylephrine infusion, a second bolus was given, and washout was recorded. After exclusion of the shunt spike, initial slope was calculated. The SMAP (mean ± standard error) increased from 65 ± 3 to 89 ± 2 mm Hg (P< 0.0001), and FMAP increased from 46 ± 3 to 63 ± 3 mm Hg (P< 0.0001); cerebral blood flow did not change (40 ± 2 to 40 ± 2 ml/100 g per min,P= 0.9199). Dividing the cases on the basis of the baseline FMAP into a “severe” hypotensive group (FMAP = 38 ± 2; n = 7) and a “moderate” hypotensive group (FMAP = 54 ± 3; n = 8), cerebral blood flow did not change in either group during phenylephrine challenge. Chronic hypotension does not necessarily result in “vasomotor paralysis” with loss of the ability to vasoconstrict to acute increases in perfusion pressure. Instead, it appears to displace adaptively the lower limit of autoregulation in affected vascular territories by a shift of the autoregulatory curve to the left, conceptually analogous to the adaptive displacement seen with chronic hypertension and its treatment.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

RECENT STUDIES DOCUMENTING the efficacy of carotid endarterectomy (CEA) in selected patients provide further impetus for developing noninvasive techniques to evaluate carotid occlusive disease. Eliminating the morbidity due to preoperative angiography would further refine the treatment of this condition. Recent improvements and greater experience with magnetic resonance angiography (MRA) of extracranial vessels have increased the accuracy of this technique. We present our experience using MRA in combination with duplex ultrasonography as the primary mode of preoperative evaluation for CEA. Fifty-two patients referred for CEA underwent these two studies. In 47 patients (90%), significant stenosis (> 70%) was unambiguously identified on both ultrasound and MRA. Forty-one of these patients underwent CEA on the basis of these studies alone, without conventional angiography. In all of these cases, significant stenosis was identified at the time of surgery (100%), and CEA was performed without difficulty or complications. In five cases (9.6%), the MRA and ultrasound findings did not concur exactly. In three of these cases, the interpretation of the two studies differed with respect to the severity of stenosis; in the others, one of the studies was indeterminate. These patients underwent conventional angiography before surgery. Our experience suggests that the combined use of MRA and ultrasonography affords an accurate noninvasive evaluation of carotid occlusive disease sufficient for surgical planning in most cases.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

WE REVIEWED 24 patients with intracranial vertebral artery dissections treated during the last 12 years. Sixteen patients were admitted with subarachnoid hemorrhage (SAH) and 8 did not have SAH. The mean age at the time of onset was 50.0 years. Male preponderance was noted. Among 21 patients with acute onset, 6 (29%) experienced prodromal neck pain and 3 (60%) of 5 SAH patients showed nuchal stiffness when examined within 6 hours of onset. The preoperative angiographical findings were uniform in SAH cases in contrast to the varied angiographical findings seen in non-SAH cases. So-called pearl and string sign was observed in most SAH cases, but the “string” was often so short and wide that the term “constriction” appeared more suitable. From intraoperative observations, the angiographical point of constriction seemed to represent the proximal or distal end of dissection. As for treatment, 19 patients underwent 20 surgeries. Trapping was performed in eight surgeries, base clipping was performed in five, and proximal clipping was performed in seven. Both trapping and base clipping prevented further bleeding, but trapping was associated with a high rate of postoperative lower cranial nerve palsy. Postoperative neurological complications were less frequent after proximal clipping, but subsequent postoperative bleeding occurred in one patient treated by this technique. The overall long-term outcome in the surgically treated cases in our series was favorable, but most patients suffered from various degrees of uncomfortable dysphagia or hoarseness for some period after surgery. It was also noted that, in half of the disabled cases, the major disability was attributable to lower cranial nerve palsy and respiratory troubles that developed postoperatively.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

A RETROSPECTIVE REVIEW is presented of 20 patients with traumatic brain injury who were treated during the course of their illness by lobectomies either after a herniation or other significant deterioration or to reduce elevated intracranial pressure. All the patients suffered from blunt head trauma. Patient ages ranged from 19 to 59 years (average, 34 yr). The initial Glasgow Coma Scale score ranged from 3 to 15 (average, 8.2). There were 14 frontal lobectomies, 2 temporal, 3 frontal and temporal, and 1 occipital. Surgery was performed between 0 and 8 days after injury (average, 2.8). Outcome was favorable (good or moderately disabled) in 11 patients and unfavorable (severely disabled, persistently vegetative, or dead) in 9. No patients survived in a persistently vegetative state. A higher initial Glasgow Coma Scale score was positively correlated with a more favorable outcome (P< 0.03). Younger patients also showed a significant positive relationship to outcome (P< 0.0005). Better pupillary reactivity showed a significant trend toward a more favorable outcome (P< 0.04). The type of lesions identified on computed tomographic scans had no association with outcome. A lobectomy can be a useful adjuvant in the management of severe brain injury, especially in younger patients with relatively higher initial Glasgow Coma Scale scores who subsequently deteriorate or develop elevated intracranial pressure.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

WE PRESENT SEVEN patients with multilevel cervical spondylotic myelopathy and superimposed midline soft disc herniation who were treated by decompressive laminectomies of the spondylotic segments followed by transdural excision of the anteriorly located disc extrusion. There was no perioperative neurological morbidity or mortality associated with this operation, and no patients have developed postoperative kyphotic deformity with an average follow-up of 50.1 months (range, 24 to 87 mo). Two patients had full neurological recovery, whereas five patients had improvement in their preoperative neurological status. We conclude that a posterior transdural approach may offer an alternative surgical option for select patients with multilevel cervical spondylosis with superimposed midline soft disc herniation in whom multiple segment decompression plus access to the anterior spinal canal is necessary.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID