ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

WITH THE COMPLETION of the Human Genome Project, the amount of molecular biological sequence data available in public databases has reached staggering proportions. Data continue to accumulate at an exponential rate in the postgenomic era. Compilation, storage, searching, sharing, studying, and transmitting of all these data present formidable challenges. To keep pace with this extant database, the science of bioinformatics (sometimes called computational biology) has evolved. Bioinformatics is the combination of biology and computers and usually involves the storage or analysis of molecular biological sequence data at either the deoxyribonucleic acid, ribonucleic acid, or protein (amino acid) level. Most bioinformatics tools are freely available on the Internet for use by investigators around the globe. The collective wisdom from bioinformatics databases worldwide will continue to spawn advances in the neurological sciences for generations to come. Neurosurgeons must be aware of the power and potential applications of bioinformatics for the analysis of neurosurgical diseases.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVEIntracranial residual and recurrent aneurysms can occur after surgical clipping, with risks of growth and rupture. In the past, surgical reoperation, which can be associated with higher risk than the initial operation, was the only available treatment. A combined neurovascular team that uses both surgical and endovascular therapies could maximize efficacy and outcomes while minimizing risks in these difficult cases. The indications for which surgical or endovascular treatment should be used to treat patients with residual or recurrent aneurysms, however, have not been elucidated well. We have reviewed the 10-year experience of our combined neurovascular team to determine in a retrospective manner which factors were important to treatment modality selection for patients with these residual and recurrent lesions.METHODSFrom 1991 to 2001, the combined neurovascular unit at the Massachusetts General Hospital treated 25 residual and recurrent previously clipped aneurysms (15 had been clipped at other centers). Only patients in whom a clip had been placed were included in the study; patients who did not have a clip placed or whose aneurysms were wrapped or coated were excluded. The radiographic studies and clinical data were reviewed retrospectively to determine the efficacy, outcomes, and factors important to the selection of treatment strategy in these patients.RESULTSThe patients’ clinical presentations were radiographic follow-up, 17 patients; rehemorrhage, 3; mass effect, 3; and thromboembolism, 2. The mean aneurysm recurrence or residual size was 11 mm (range, 4–26 mm). The mean interval until representation was 6.6 years (range, 1 wk–25 yr). Treatment consisted of: coiling, 11 patients; reclipping, 8; proximal parent vessel balloon occlusion, 2; extracranial-intracranial bypass with coil occlusion of aneurysm and parent vessel, 2; extracranial-intracranial bypass with clip trapping, 1; and extracranial-intracranial bypass with proximal clip occlusion of parent vessel, 1. The mean radiographic follow-up period was 11 months. Complete angiographic occlusion was found in 19 aneurysms (76%), at least 90% occlusion was found in 4 aneurysms (16%), intentional partial coil obliteration was found in 1 fusiform lesion (4%), and intentional retrograde flow was found in 1 fusiform lesion (4%). Clinical outcomes were excellent or good in 19 patients (76%). Twenty-one patients (84%) were neurologically the same after retreatment (13 remained neurologically intact, and 8 had preexisting neurological deficits that did not change). Three patients (12%) had new neurological deficits after retreatment, and one patient (4%) died. There were four complications of retreatment (16%), one of which was a fatal hemorrhage in a patient 1 month after intentional partial coil obliteration of a fusiform vertebrobasilar junction aneurysm. Factors important to the selection of treatment modality were recurrence or residual location (all posterior circulation lesions were treated endovascularly), lesion size (lesions larger than 10 mm were treated endovascularly or with the use of combined techniques), and aneurysm morphology (fusiform and wide-necked lesions were treated endovascularly or with the use of combined techniques).CONCLUSIONThe proper selection of surgical or endovascular treatment for residual and recurrent previously clipped aneurysms can achieve excellent radiographic efficacy with low mortality. Factors important to the selection of treatment by this combined neurovascular team were posterior circulation location, aneurysm size larger than 10 mm, and fusiform morphology, which were treated endovascularly or with the use of combined techniques because of the higher surgical risk associated with these factors. For aneurysms with lower surgical risk, such as some anterior circulation aneurysms and aneurysms smaller than 10 mm, we prefer to perform a reoperation because of superior radiographic cure without compromising the outcome.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVETo analyze surgical results for the highly variable Spetzler-Martin Grade III arteriovenous malformations (AVMs), to demonstrate that outcomes vary among the different types of Grade III lesions, and to introduce a simple modification of the grading scale that might improve its usefulness for these AVMs.METHODSIn a consecutive series of 174 brain AVMs resected from 174 patients during a period of 4.8 years, 76 AVMs (45.2%) were Grade III. There were 35 small AVMs (S1V1E1) (46.1%), 14 medium/deep AVMs (S2V1E0) (18.4%), and 27 medium/eloquent AVMs (S2V0E1) (35.5%). No large Grade III AVM (S3V0E0) was treated.RESULTSComplete AVM resection was accomplished for 74 patients (surgical obliteration rate, 97.4%). Three patients (3.9%) experienced permanent, treatment-associated, neurological morbidity, and three patients died (surgical mortality rate, 3.9%). Good outcomes (Rankin scale scores of ≤2) were observed for 59 patients (78.7%). Surgical risks (new deficit or death), according to the Grade III type, were 2.9% for small AVMs (S1V1E1), 7.1% for medium/deep AVMs (S2V1E0), and 14.8% for medium/eloquent AVMs (S2V0E1).CONCLUSIONGrade III AVMs are a heterogeneous group, with each type possessing different surgical risks, and the Spetzler-Martin grading scale should be modified accordingly. Grade III− AVMs (S1V1E1) have a surgical risk similar to that of low-grade AVMs and can be safely treated with microsurgical resection. Grade III+ AVMs (S2V0E1) have a surgical risk similar to that of high-grade AVMs and are best managed conservatively. Grade III AVMs (S2V1E0) have intermediate surgical risks and require judicious selection for surgery. Grade III* AVMs (S3V0E0) are either exceedingly rare, with a surgical risk that is unclear, or theoretical lesions with no clinical relevance.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVETentorial dural arteriovenous malformations (DAVMs) are uncommon lesions associated with an aggressive natural history. Controversy exists regarding their optimal treatment. We present a single-institution series of tentorial DAVMs treated during a 12-year period, address the current controversies, and present the rationale for our current therapeutic strategy.METHODSTwenty-two patients with tentorial DAVMs were treated between 1988 and 2000. Treatment consisted of transarterial or transvenous embolization, surgical resection, disconnection of venous drainage, or a combination of these therapies. The clinical presentations, radiological features, treatment strategies, and results were studied.RESULTSEighteen patients (82%) presented with intracranial hemorrhage or progressive neurological deficits. Retrograde leptomeningeal venous drainage was documented in 22 cases (100%), classifying the lesions as Borden Type III. Angiographic follow-up monitoring was performed for 0 to 120 months and clinical follow-up monitoring for 1 to 120 months. Posttreatment angiography demonstrated obliteration in 22 cases (100%). Two patients experienced neurological decline after endovascular treatment and died. All of the 20 surviving patients exhibited clinical improvement; there were no episodes of rehemorrhage or new neurological deficits. Outcomes were excellent in 17 cases (77%), good in 2 cases (9%), and fair in 1 case (5%), and there were 2 deaths (9%).CONCLUSIONTentorial DAVMs are aggressive lesions that require prompt total angiographic obliteration. Disconnection of the venous drainage from the fistula may be accomplished with transarterial embolization to the venous side, transvenous embolization, or surgical disconnection of the fistula. We think that extensive nidal resections carry more risk and are unnecessary. We do not think there is a role for stereotactic radiosurgery in the treatment of these lesions.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVEThe purpose of this study was to identify factors predictive of shunt-dependent hydrocephalus among patients with aneurysmal subarachnoid hemorrhage. The data can be used to predict which patients in this group have a high probability of requiring permanent cerebrospinal fluid diversion.METHODSSeven hundred eighteen patients with aneurysmal subarachnoid hemorrhage who were treated between 1990 and 1999 were retrospectively studied, to identify factors contributing to shunt-dependent hydrocephalus. With these data, a stepwise logistic regression procedure was used to determine the effect of each variable on the development of hydrocephalus and to create a scoring system.RESULTSOverall, 152 of the 718 patients (21.2%) underwent shunting procedures for treatment of hydrocephalus. Four hundred seventy-nine of the patients (66.7%) were female. Of the factors investigated, the following were associated with shunt-dependent hydrocephalus, as determined with a variety of statistical methods: 1) increasing age (P< 0.001), 2) female sex (P= 0.015), 3) poor admission Hunt and Hess grade (P< 0.001), 4) thick subarachnoid hemorrhage on admission computed tomographic scans (P< 0.001), 5) intraventricular hemorrhage (P< 0.001), 6) radiological hydrocephalus at the time of admission (P< 0.001), 7) distal posterior circulation location of the ruptured aneurysm (P= 0.046), 8) clinical vasospasm (P< 0.001), and 9) endovascular treatment (P= 0.013). The presence of intracerebral hematomas, giant aneurysms, or multiple aneurysms did not influence the development of shunt-dependent hydrocephalus.CONCLUSIONThe results of this study can help identify patients with a high risk of developing shunt-dependent hydrocephalus. This may help neurosurgeons expedite treatment, may decrease the cost and length of hospital stays, and may result in improved outcomes.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVEInvasive tumors involving the cavernous sinus, such as recurrent benign meningiomas or sarcomas, raise therapeutic problems that may be resolved by cavernous sinus exenteration (CSE).METHODSOur series comprises 18 patients (9 women and 9 men ranging in age from 14 to 64 yr) who underwent CSE during the past 8 years. The tumors in these patients included 12 meningiomas, 3 chondrosarcomas, 1 rhabdomyosarcoma, 1 lipomyosarcoma, and 1 epidermoid carcinoma. Preoperative occlusion of the internal carotid artery was confirmed in 15 cases by a balloon occlusion test. Three patients had a negative balloon occlusion test, and their internal carotid arteries were preserved (n = 1) or revascularized (n = 2) through an external carotid artery-to-middle cerebral artery bypass.RESULTSCSE was performed as a primary treatment in 5 patients and after one to five recurrences in 13 patients. In all patients, CSE included the internal carotid artery and Cranial Nerves III, IV, and VI and one to three branches of Cranial Nerve V. Orbital exenteration was performed in eight patients, and partial hypophysectomy was performed in five patients. Ten patients had received radiotherapy before CSE, and five patients underwent irradiation after CSE. The operative mortality includes two patients. Cerebrospinal fluid leakage was the main complication in four patients, with three patients having meningitis. Follow-up ranged from 6 months to 5 years, with three deaths from new recurrences at 2, 3, and 4 years after CSE. As compared with their clinical courses before CSE, all patients except the two who died postoperatively benefited from CSE.CONCLUSIONCSE has useful indications in invasive and rapidly growing tumors, including apparently benign meningiomas. A better understanding of the biological behavior of these tumors is necessary for appropriate selection of patients for CSE.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVEWe reviewed the clinical and radiological features of 73 cases of trigeminal neuromas treated with radical surgery.METHODSThe records for 73 patients with trigeminal neuromas who were surgically treated in the neurosurgery department of King Edward VII Memorial Hospital and Seth Gordhandas Sunderdas Medical College (Mumbai, India), between 1989 and 2001, were retrospectively analyzed. The appropriateness of the selected surgical route was studied. The postoperative and follow-up data for the patients were analyzed, to determine the outcomes of radical surgery.RESULTSIn addition to the other presenting features of trigeminal neuromas, nine patients presented with the rarely reported symptom of pathological laughter. Three approaches were observed to be appropriate for treatment of these tumors, i.e., the infratemporal fossa interdural approach, the lateral basal subtemporal approach, and the retrosigmoid approach. In 51 cases (70%), total tumor excision was achieved. Two patients died during the postoperative period. With an average follow-up period of 38 months, there has been a recurrence in 1 case and 71 patients are leading independent and active lives.CONCLUSIONRadical surgery is associated with excellent clinical outcomes and long-term tumor control. A majority of tumors, even those that are large and multicompartmental, can be removed in a single surgical stage and exposure.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVEThis study assessed the neuropsychological outcome of patients after surgical treatment for third ventricle brain tumors. Neuropsychological consequences of surgical intervention can have a major impact on patients’ quality of life and therefore have important implications for treatment planning.METHODSA retrospective analysis of 33 patients’ neuropsychological data was performed. All patients received a comprehensive neuropsychological evaluation after treatment for a primary brain tumor in the third ventricular region. Twenty-six patients underwent surgery, 14 via the transcallosal approach and 12 via a subfrontal, left transcortical, right pterional, or infratentorial supracerebellar approach. Seven patients were not treated by surgical intervention.RESULTSThere was a significantly elevated frequency of cognitive impairment relative to normative values in memory, executive functioning, and fine manual speed and dexterity. There were no differences in mean neuropsychological scores between patients who underwent surgery and those who did not. There were no differences in mean performance on the basis of surgical approach, tumor infiltration, or history of cranial irradiation. Repeated measures data available for two patients revealed memory impairment before and after surgery, and one patient experienced major improvement after surgery on a measure of mental flexibility and problem solving.CONCLUSIONPatients with third ventricle tumors are at risk for developing impairments in memory, executive function, and fine manual speed and dexterity, which are domains associated with frontal subcortical functions. In the current study, different types of treatment were not associated with differential cognitive sequelae, and surgical intervention did not account for cognitive deficits.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID