摘要:

TO DEFINE THE outcomes after stereotactic radiosurgery performed for smaller volume arteriovenous malformations (AVMs) that are potentially suitable for surgical removal, we retrospectively reviewed our 4-year experience in 65 patients who declined microsurgery. All 65 patients had Spetzler-Martin Grade I or II AVMs and a minimum follow-up of 24 months (median, 29 mo). Symptomatic improvement after radiosurgery occurred in 52% of patients with seizures and in 63% of patients with headaches. The annual risk of AVM hemorrhage during the latency interval after radiosurgery was 3.7%. Five patients (7.7%) had a subsequent hemorrhage (all within 8 mo of radiosurgery); two died, and three recovered (one after hematoma evacuation and two with conservative management). Forty-seven patients (72%) returned to their previous employment status or activity level within 1 week of radiosurgery (92% within 1 yr). No patient suffered radiation-related complications. Twenty-seven (84%) of 32 patients evaluated by postradiosurgical angiography had complete AVM obliteration. Radiosurgery is an effective and less invasive management strategy for Grade I or II AVM patients who are either medically unsuitable for or unwilling to undergo surgical removal. The risk of AVM hemorrhage during the latency interval until obliteration occurs appears to be no different than the natural history of untreated AVMs. These results (including hemorrhage prevention and symptom amelioration) indicate that the conservative management of small AVMs can rarely be justified.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

UP TO 6% of cerebral aneurysms may be familial. Because the pattern of inheritance and the prevalence of aneurysms within families are unknown, the management of family members at risk of harboring a cerebral aneurysm is currently empirical. We established the prevalence of aneurysms in the second generation of individuals with familial cerebral aneurysms and determined the possible benefit of angiographic screening and elective surgery of such individuals by using a simple decision analysis model. Four consecutive families were identified in whom the mother and a child had a ruptured cerebral aneurysm. A total of 19 siblings at risk in the second generation were identified. Fifteen underwent elective cerebral angiography: one had a cerebral aneurysm and two had an infundibulum at the origin of the posterior communicating artery. Including the previously known aneurysms, the prevalence of aneurysms in the second generation was thus established at 29.4%. A decision analysis was performed with 2% as the annual risk of rupture, 72.7% as the risk of death or disability with rupture, 0.1% as the risk of angiography, and 6.5% as the risk of surgery. The benefit in years of survival free of sequelae resulting from angiographic screening and elective surgery (intervention) over natural history was computed for life expectancy corresponding to each quinquennial age group from age 15 to 100 years. Intervention equaled natural history, in terms of years of survival expected with each choice, at a life expectancy of 10.6 years, corresponding to age 76.5 years for men and 80 years for women, and produced a net gain of at least 1 year for patients whose life expectancy was 32 years or more, corresponding to age 53.5 years for women and 49 years for men. Greater benefit was achieved with increasing life expectancy (younger age). The prevalence of aneurysms in the second generation when a mother and child have an aneurysm is 29.4%. Intervention produces a benefit of at least 1 year of survival free of sequelae over natural history in such individuals if their life expectancy is 32 years or more.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

THE CAUSE OF moyamoya disease remains unknown, and pathophysiological mechanisms remain uncertain. Basic fibroblast growth factor (FGF) is a pluripotent polypeptide that has been shown to play roles in angiogenesis, tumorigenesis and many other processes. In a previous study, we demonstrated immunohistochemically that the amount of basic FGF was increased above normal in the superficial temporal artery (STA) of patients with moyamoya disease. To clarify the function of basic FGF in moyamoya disease, we have performed an immunohistochemical study of the STA using a polyclonal antihuman FGF receptor antibody and also have tested immunohistochemical reactions for basic FGF. Twelve surgical specimens of the STA from patients with moyamoya disease were studied. Twelve specimens of the STA from skin flaps of patients with other neurological diseases were also investigated for comparison. The sections of the STA from patients with moyamoya disease showed dense and strong FGF receptor and basic FGF immunoreactivity in endothelial cells, in cells scattered in the thickened intima, and in smooth muscle cells in the media. In contrast, the sections of the STA of control patients showed faint basic FGF immunoreactivity. The statistical analysis revealed a significant difference of basic FGF immunoreactivity between moyamoya disease and other neurological diseases (χ2= 23;P= 0.0001). Moderately intense FGF receptor immunoreactivity was observed in most control patients. However, the statistical analysis revealed a significant difference of FGF receptor immunoreactivity between moyamoya disease and other neurological diseases (χ2= 13.382;P= 0.0012). Results of these experiments indicate that the amounts of basic FGF and FGF receptor are increased in the STA of patients with moyamoya disease and that both basic FGF and its receptor exist in smooth muscle cells. Thus, smooth muscle cells with abundant basic FGF may stimulate themselves via an autocrine mechanism and migrate to and thicken the intima of patients with moyamoya disease.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

WE PERFORMED HEMOSTATIC studies on eight patients undergoing clipping of unruptured cerebral aneurysms to assess the influence of intracranial surgery itself on hemostasis. Blood samples were collected from each patient 10 times: before and after the induction of anesthesia and 6, 12, and 24 hours and 2, 3, 5, and 7 days immediately after surgery. The changes and our interpretation of them include the following: 1) the elevation of thrombin antithrombin III complex levels (activation of blood coagulation) was transient and monophasic; 2) the elevation of plasmin α2-antiplasmin complex and D-dimer levels (activation of fibrinolysis) was biphasic, despite the monophasic elevation of tissue plasminogen activator or plasminogen activator inhibitor-1 levels; 3) the elevation of β-thromboglobulin and platelet-factor-4 levels (activation of platelet) was also biphasic; 4) fibrinogen level and α2-antiplasmin activity increased in the acute phase of the postoperative course (acute phase reaction); 5) the changes in hematocrit appeared to parallel those in various other parameters, especially platelet count, antithrombin III, and plasminogen levels for 1 or 2 days after surgery; 6) fibronectin appeared to be consumed in the acute phase of postoperative course; and 7) general anesthesia did not significantly affect hemostasis. These serial changes seem to be related to the activation of hemostatic systems after intracranial surgery and the subsequent acute phase reaction.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

THE AUTHORS REPORT the outcome of surgical treatment in a group of 25 patients with cavernous angioma of the orbital cavity. In the majority of cases, good esthetic results were appreciable within a few days of surgery. However, the onset or deterioration of preexisting visual deficits, in spite of the complete preservation of the optic nerve in a third of these patients, draws attention to the need for accurate surgical timing.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

ONLY TWO CASES have been reported of a pituitary adenoma that changed phenotype between its initial resection and recurrence. To determine the frequency of such cases among our patients, we examined the clinical course of these tumors and characterized any patterns. We reviewed the charts of 1023 patients with pituitary adenomas who underwent surgery between 1984 and 1992 at the University of California at San Francisco. Of the 65 patients (6.4%) who had operations for or clinical evidence of tumor recurrence, five (7.7%) had tumors that changed phenotype. The female-to-male ratio was 4:1, and age at the onset of symptoms was 33.2 ± 15.3 years (mean ± standard deviation). Changes occurred in hormone production and hormone release after 6.4 ± 3.4 years. At some point, all five tumors were invasive and four were macroadenomas. Two patients had more than one operation for tumor recurrence; three had silent or symptomatic pituitary apoplexy; and three had undergone sellar irradiation before the changes in phenotype occurred. The behavior of these tumors therefore seems to be aggressive. We do not yet know whether phenotypic changes in pituitary adenomas have any treatment implications. Therefore, we advocate the complete immunostaining of primary and recurrent pituitary adenomas so that additional data about their clinical course can be collected.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

BOTH EARLY AUDITORY evoked potentials (BAEPs) and middle-latency auditory evoked potentials (MLAEPs), were recorded in nine patients suffering from a quadrigeminal plate tumor. These recordings were performed before surgery in six cases and after surgery in three cases. The results of these examinations were correlated with impairments of the midbrain auditory pathways as shown by magnetic resonance imaging. BAEPs and MLAEPs were abnormal in five of nine cases and eight of nine cases, respectively. The two examinations yielded normal results in only one case. These data show that the functional evaluation of the midbrain should not be limited to the recording of BAEPs, routinely performed for brain stem functional evaluation, but should also include recording of MLAEPs, although the technique is a little more delicate. In the five patients with abnormal BAEPs, I-V conduction time was increased unilaterally (three patients) and bilaterally (two patients), and the I/V amplitude ratio was abnormal in two patients. In one of these two patients, isolated destruction of the right inferior colliculus was responsible for an abnormality affecting Wave V of the BAEP that was visible only after left ear stimulation. The most frequently observed MLAEP abnormality was a delay in the peaking of the Pa component, assumed to be of cortical origin. Therefore, a limited impairment of the midbrain may delay the peaking latency of Pa. Unilateral hypovoltage of Na-Pa was also observed. In only one case were Na and Pa components unilaterally abolished, in a patient suffering from a postoperative lesion extending from the right inferior colliculus to the right medial geniculate body. Although the generators of the Na component are still a matter of dispute, our recordings show that a midbrain lesion may alter this component.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

THE INTEGRITY OF language function after a left (dominant) anterior temporal lobectomy performed without the use of functional mapping remains controversial. Much of the controversy concerns the degree to which analyses of group data obscure the identification of surgically induced dysnomia in individual patients. This study investigated postoperative language outcome in our entire series (n = 162) of nonretarded, left hemisphere speech dominant patients with intractable nonlesional epilepsy who underwent a left (n = 85) or right (n = 77) anterior temporal lobectomy without functional mapping. A comparison of preoperative to (6 mo) postoperative performance on a standardized test of nominal speech revealed the following: 1) a statistically significant but clinically modest difference in outcome between left and right anterior temporal lobectomy groups; 2) a subgroup (7%) of left anterior temporal lobectomy patients exhibited a postoperative dysnomia (a decline in nominal speech that exceeded the worst performance in the right anterior temporal lobectomy group); and 3) a postoperative decline in nominal speech after left anterior temporal lobectomy was specifically associated with a later age at the onset of epilepsy. Within the context of group data suggesting minimal risk to language function when functional mapping is not used, a small subgroup of individuals characterized by a later onset of epilepsy can be identified who exhibit a surgically induced dysnomia after a standard left anterior temporal lobectomy. Whether these results differ from the outcome of functional mapping remains to be determined.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

THE RESULTS OF selective peripheral denervation in 50 patients with spasmodic torticollis are presented. Of our patients, 76% reported a significant improvement or disappearance of their dystonia. The mean follow-up is 25 months. There were no major side effects. We recommend the procedure to patients who primarily have responded to botulinum toxin therapy and had become secondary nonresponders or to those refusing further injections while still responding. The results are much less promising in patients who are primary nonresponders to botulinum toxin. Some remarkable histological findings are presented. The posterior branches of the cervical roots frequently showed signs of severe compression neuropathy. In three cases, a functional motor nerve regeneration was proved. Among all surgical options, selective peripheral denervation provides the best result and has the fewest side effects.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

FROM 1974 TO 1992, anterior cervical spondylodesis was performed in 163 patients of cervical spondylotic myelopathy, cervical spondylotic radiculopathy, traumatic spinal injury, ossification of the posterior longitudinal ligament, or cervical spondylitis. Forty-five of these patients were followed for more than 4 years. To analyze the long-term results of anterior cervical spondylodesis, a radiological examination was performed in these 45 patients and magnetic resonance imaging was conducted in 41 of them. Postoperative spondylotic changes were observed radiologically in 23 (51.1%) of the 45 patients. Anterior bony spur was more frequently observed than posterior bony spur in these postoperative spondylotic changes. Postoperative canal stenosis caused by the bulging of the discs and the ligamentum flavum was frequently demonstrated with hypo- or isointense signal on T2-weighted images by magnetic resonance imaging in patients followed long term after surgery and in patients with malalignment of the cervical spine due to kyphosis of the fused vertebrae and multisegmental fusion. Neurological improvement was less in patients with bulge of the discs and the ligamentum flavum seen in magnetic resonance imaging than in patients without it. The bulge of the ligamentum flavum was histopathologically defined as hypertrophy of the ligament.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID