摘要:

PATHOLOGICAL AND CLINICAL data from 56 patients operated on for craniopharyngioma since 1981 were analyzed to determine the utility of dividing patients with this tumor into distinct clinical groups based on recognized pathological type and to determine the prognostic import of brain invasion. Of the tumors in the 30 adult patients, 66% were adamantinomatous, 28% were squamous papillary, and the remainder were mixed. However, of the tumors in the 26 children, 96% were adamantinomatous and none were pure squamous papillary (P< 0.01). Forty-six percent of the children compared with 17% of the adults had brain invasion (P< 0.01). Brain invasion was present in 37% of the adamantinomatous but in only 13% of the squamous papillary tumors. Seventy-seven percent of the children underwent gross total resection (GTR) compared with 27% of the adults (P< 0.01). Sixty-three percent of the squamous papillary tumors underwent GTR compared with 54% of the adamantinomatous and mixed tumors. Follow-up ranged from 7 to 187 months (mean, 49 mo). After subtotal resection, with or without radiation therapy, 58% of the tumors recurred compared with 17% recurrence after GTR (P< 0.01), with a mean time to recurrence of 34 months. In both tumor histological types, subtotal resection was associated with a higher rate of tumor recurrence compared with gross total resection. Among the subtotally resected craniopharyngiomas, 2 of the 3 (67%) squamous papillary and 11 of the 21 (52%) adamantinomatous and mixed tumors recurred. In contrast, among the totally resected tumors, none of the 5 squamous papillary and only 5 of the 25 (20%) adamantinomatous and mixed tumors recurred. There were no significant differences in Karnofsky performance status score, mortality rate, or visual and endocrine outcomes when comparing patients based on histological tumor type. When controlling for age and extent of resection, we found that brain invasion had no significant effect on recurrence rate in totally resected tumors. Based on the limited number of patients in this series, we conclude as follows. 1) Contrary to previous reports, squamous papillary craniopharyngiomas, like adamantinomatous tumors, may recur when subtotally resected. 2) For both tumor variants, the most significant factor associated with craniopharyngioma recurrence is the extent of surgical resection rather than histopathological subtype. 3) Contrary to prior hypotheses, brain invasion in totally resected tumors does not predict higher recurrence. 4) GTR is associated with a significantly lower recurrence rate and can be achieved without sacrificing functional outcome.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

CRANIOPHARYNGIOMAS ARE HISTOLOGICALLY benign epithelial neoplasms of the sellar region that frequently exhibit invasive and aggressive local growth. In this study, we have investigated the presence and cellular distribution of estrogen receptor messenger ribonucleic acid by in situ hybridization in 23 surgically removed craniopharyngiomas. All craniopharyngiomas studied, including 19 adamantinomatous and 4 papillary variants, uniformly expressed the estrogen receptor gene. In all cases, an intense estrogen receptor messenger ribonucleic acid hybridization signal was demonstrated; one localized exclusively to the epithelial cells of the tumor. Connective tissue and vascular elements were devoid of hybridization signal. Coexpression of the estrogen receptor protein was also studied by immunohistochemistry. Despite the relative abundance of estrogen receptor message in all cases studied, the estrogen receptor protein was focally but conclusively detected in only two tumors. The basis of this discrepancy is unclear. Progesterone receptor protein was also studied in all cases; however, its definitive presence was noted in only one instance and, in that case, in only occasional nuclei. The expression of the estrogen receptor gene by the proliferative epithelial elements of craniopharyngiomas raises the questions of a possible hormonal component to the genesis and/or progression of the craniopharyngiomas and a potential responsiveness to therapeutic hormonal manipulation.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

THE RECORDS OF 137 patients with supratentorial oligodendroglioma treated surgically between 1953 and 1986 were reviewed. The tumors were rated histologically benign or malignant. In the 105 patients followed up with a minimum observation time of 5 years to December 1991, the mean postoperative survival was 90.2 months (standard error, 9), the median 64 months (standard error, 9.6), the 5-year survival rate 52.4%, and the 10-year survival rate 24%. Sixteen possible prognostic factors, broken down into two or more variables each, were considered in the survival study on univariate methods (5-year survival rate, survival curves, and Cox's hazard function) and on multivariate analysis according to Cox's stepwise proportional hazards model. The latter showed that variables correlated positively with survival were benign histological findings (P, 0.000), postoperative radiation therapy (P, 0.004), and time of operation from 1977 to 1986 (P, 0.044) in 105 patients of the whole series, and period of surgery from 1977 to 1986 (P, 0.000), subtotal or total surgical resection of the tumor (P, 0.001), and radiation therapy (P, 0.005) in the subgroup of 79 patients operated on for benign tumors. However, the most interesting point to emerge from the study was the relevance of admission clinical status to the survival of patients who did not receive radiation therapy and to the prognostic response of those who did. Of the 40 patients with seizures and negative neurological status—Clinical Syndrome A—the 10 who did not receive radiation therapy had survived as long as the 30 who did (5-year survival rate, 80 versus 67%;P, not significant; median survival, 122 versus 85 months; Breslow and Mantel-CoxP, not significant), whereas of the 65 patients with intracranial hypertension and/or neurological deficits—Clinical Syndrome non-A—the 18 who did not receive radiation therapy had short survival times, and the 47 who did fared significantly better (5-year survival rate, 11 versus 53%;P, 0.002; median survival, 32 versus 64 months; Breslow and Mantel-CoxP, 0.000). These findings were not significantly affected by the exclusion of malignant neoplasms and in the group of benign tumors, in which the histological characteristics have not been found to be significantly different between those with A and those with non-A clinical syndrome, did not depend on different frequencies of subtotal or total tumor removal. In fact, multivariate analyses for benign tumors only demonstrated that the variables that correlated with survival were radiation therapy (P, 0.000) and preoperative history less than 12 months (P, 0.006) in 47 patients with Syndrome non-A, and subtotal or total surgical removal of the tumor (P, 0.005) and additional operations (P, 0.027) in 32 patients with Clinical Syndrome A. These results supply a reasonable explanation for the better survival and the unresponsiveness to radiation therapy of our patients who received surgical treatment since the introduction of computed tomography from 1977 to 1986. On the basis of this review, we believe that patients with cerebral oligodendrogliomas, when histologically benign, should be classified by clinical status at admission in two groups, and that treatment should be organized and survival assessed on that basis. It seems that the two clinical syndromes correspond to different periods in the life history of the tumor.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

PROLIFERATING CELL NUCLEAR antigen, an auxiliary protein of deoxyribonucleic acid polymerase-δ, has been shown to be a reliable marker of nuclear deoxyribonucleic acid synthetic activity. We applied a monoclonal antibody to proliferating cell nuclear antigen to a series of serial stereotactic biopsies from patients with glioblastoma multiforme and found the proliferative activity to vary relative to biopsy location within or surrounding the solid tissue component of the tumor. Twenty-seven trajectories in 26 patients were analyzed, each consisting of two to five sequential 10 × 1.5 mm core biopsies (mean = 3). The proliferative index (PI) was greatest in those cells located at the solid tumor-infiltrated parenchyma interface. PI values were significantly lower in those biopsy cores located proximal (within infiltrated parenchyma) and distal (within solid tumor tissue) to the solid tumor-infiltrated parenchyma interface (median PI values, proximal to distal: 0.38, 0.66, 5.45 [solid tumor-infiltrated parenchyma interface], 0.39, 0.09%). The mean PI values were significantly lower in neoplastic cells sampled from regions of peripheral hypodensity on computed tomographic scans compared with those sampled from contrast-enhancing regions (0.9 and 3.91%, respectively). There was no significant difference in the mean PI values of neoplastic cells sampled from regions of contrast enhancement or central hypodensity (3.91 and 4.31%, respectively).

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

THE RESULTS IN the surgical management of 26 patients with arteriovenous malformations intimately related to the trigone of the lateral ventricle are presented. Three operative approaches were used in the series, including a transtemporal route through the inferior or middle temporal gyrus (15 patients), an interhemispheric approach (8 patients), and a transcortical parieto-occipital approach (3 patients). The surgical approach was chosen on the basis of the relationship of the arteriovenous malformation to the trigone, the presence and location of associated hematoma, and preoperative neurological deficits. This report emphasizes the use of surgical adjuncts that are instrumental in the management of these challenging lesions, including magnetic resonance imaging for precise localization and operative planning, preoperative embolization to obliterate deep arterial supply, and intraoperative ultrasound and angiography to aid in localization and to document complete excision of the arteriovenous malformation before closure. The results of the management of these 26 patients are as follows: 21 had no or minor neurological deficits and were able to resume premorbid activities; 2 had a fair result, being independent but unable to resume their premorbid occupation; 2 had a poor result and were dependent as the result of an incapacitating neurological deficit; and 1 died.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

THROMBIN-ANTITHROMBIN III COMPLEX (TAT) and plasmin-α2-plasmin inhibitor complex (PIC) were examined in the acute stage in 51 patients with nontraumatic subarachnoid hemorrhage. TAT and PIC values were correlated with severity at the time of onset and with outcome. In the patients whose TAT levels were 25 ng/ml or more and PIC levels were 3.0 μg/ml or more (n = 16), only 25% had a good or fair outcome. In the patients with TAT levels less than 25 ng/ml or PIC levels less than 3.0 μg/ml (n = 35), on the other hand, 82.9% had a good or fair outcome. There were no significant differences in TAT and PIC levels between patients who experienced arterial spasm and those who did not. These results indicate that TAT and PIC values may reflect the severity of the brain damage induced by subarachnoid hemorrhage. It is speculated that marked coagulation and fibrinolytic disorders occur in the acute stage of subarachnoid hemorrhage.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

THIS STUDY EXAMINES the surgical practice at the Wessex Neurological Centre over the 5-year period from 1989 to 1993 to determine the incidence of postoperative hematoma and to identify risk factors for a perioperative bleeding disorder. The study includes only those postoperative hematomas (at any site) that followed and were related to a neurosurgical operation and were surgically evacuated. The study is prospective for the year 1993 and retrospective for the preceding years. Over the 5 years, 6668 operations were performed and 71 postoperative hematomas were surgically evacuated, accounting for an overall rate of 1.1% of operations. The records were available for 69 cases. The most frequent diagnosis leading to postoperative hematoma was meningioma surgery with a rate of 6.2% of cases (13 of 211); followed by craniotomy for trauma, 3.7% (7 of 192); aneurysm surgery, 2.6% (11 of 428); and intrinsic supratentorial tumors, 2.2% (10 of 451). Postoperative hematomas were intraparenchymal in 43% of cases, subdural in 5%, extradural in 33%, mixed in 8%, and confined to the superficial wound in 11%. The overall mortality was 32% (37% for intraparenchymal and 12% for extradural). Risk factors for a perioperative bleeding disorder were present in two-thirds of the patients. Administration of antiplatelet agents (aspirin and nonsteroidal anti-inflammatory drugs) was the most commonly associated risk factor. At least 75% of these identified risk factors could potentially have been avoided or corrected.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

MYOGENIC MOTOR-EVOKED RESPONSES to transcranial magnetic stimulation of the motor cortex (tcmag-MERs) may become clinically useful for the noninvasive assessment of motor pathway conduction during surgery. However, application is hindered because most anesthetic regimens result in severe depression of tcmag-MER amplitudes. As part of our systematic attempts to identify anesthetic agents and supplements suitable for use during tcmag-MER recording, we studied the effect of bolus doses of pentobarbital (1.5 mg/kg), droperidol (0.07 mg/kg), or ketamine (1 mg/kg), administered intravenously, on compound muscle action potentials to transcranial magnetic stimulation in five healthy volunteers. The doses were chosen to be comparable with doses that might be suitable for supplementation of a nitrous oxide/opioid anesthetic technique. Droperidol administration resulted in sustained amplitude depression of both tibialis and adductor pollicis tc-MERs to 30 ± 9% and 39 ± 14% of baseline (P< 0.01). Tcmag-MER amplitude changes after pentobarbital were variable, ranging from no change to substantial amplitude depression (to 20% of baseline) in two subjects. In contrast, ketamine administration did not result in significant amplitude depression. In three subjects, tibialis anterior amplitude increased to 150 to 220% of control values in the first 10 minutes after ketamine. Onset latency was unchanged after any drug. These data indicate that tcmag-MERs are moderately depressed after droperidol and pentobarbital but well preserved after ketamine. Ketamine may be a more suitable supplement to opioid/nitrous oxide anesthesia than droperidol or pentobarbital.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

FIFTY-TWO PATIENTS WITH unstable degenerative spondylolisthesis treated with the “AO internal fixator” and posterolateral fusion were reviewed. The major purpose of this study is to observe whether this pedicle fixation system could adequately decompress the nervous system tissue by the restoration of the spinal canal and, hence, replace the conventional decompressive laminectomy for the treatment of this disease entity. The results were satisfactory, showing that 92% of the patients with radicular pain, 89% of the patients with low back pain, and 86% of the patients with intermittent claudication improved postoperatively. Observing the results, only two groups of patients with unstable degenerative spondylolisthesis are not suitable for this treatment modality. The first group consists of those patients who have a spondylolisthesis with borderline instability. The second group consists of those patients who have a positive Lasèque's sign.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

THE EVALUATION OF peripheral nerve disorders has traditionally relied on a clinical history, physical examination, and electrodiagnostic studies. Recent studies have used magnetic resonance imaging (MRI) to evaluate a variety of both nerve and muscle disorders. In this article, we describe the use of MRI, using short-tau inversion recovery (STIR) sequences, to evaluate muscle signal characteristics in a variety of peripheral nerve disorders. A total of 32 patients were studied, and 12 representative cases are discussed in detail. Increased STIR signal in muscle was seen in cases of severe axonotmetic injuries involving the transection of axons producing severe denervation changes on electromyography. The increased STIR signal in denervated muscles was seen as early as 4 days after the onset of clinical symptoms, which is significantly earlier than changes detected on electromyography. The MRI signal changes were reversible when the recovery of motor function occurred as a result of further muscle innervation. In cases of neurapraxic nerve injuries, characterized by conduction block without axonal loss, the STIR signal in muscle was normal. These findings show that MRI using STIR sequences provides a panoramic visual representation of denervated muscles useful in localizing and grading the severity of peripheral nerve injury secondary to either disease or trauma. MRI using STIR sequences may therefore play an important role in the prediction of clinical outcome and the formulation of appropriate therapy early after peripheral nerve injury.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID