Benjamin Brown

Fatal consequences of a simple mistake: How can a patient be saved from inadvertent intrathecal vincristine?

Since its introduction in 1963, vincristine sulfate, commonly nown as vincristine, has been widely used as a chemotherapeutic gent for a variety of malignancies including lymphoma, leukemia, habdomyosarcoma, neuroblastoma, andWilms tumor. Vincristine s administered intravenously as bolus often in combination with ther multidrug chemotherapy regimen. Despite its long-term extensive use and the Food and Drug dministration recommended box label warning, there have been number of cases in which vincristine was inadvertently adminisered intrathecally. If administered intrathecally, vincristine causes evere and irreversible central nervous system toxicity and motor ysfunction followed by progressive ascending radiculomyeloenephalopathy, coma and death [1]. The error generally occurswhen incristine is confused with therapeutic agents normally adminisered intrathecally, such as methotrexate or cytarbine. Intrathecal dministration of vincristine was first described to cause a fatal scending myeloencephalopathy in humans in 1968 in the United tates [2]. Since then, over 16 cases in the United States and ver 60 cases worldwide have been reported in the literature [3]. owever, the true incidence of inadvertent intrathecal vincristine dministration is not known. Some of these incidents, particuarly lethal events, prompt publication and others reported to rganizations such as the Institute for Safe Medication Practices.

The Pterional and Suprabrow Approaches for Aneurysm Surgery: A Systematic Review of Intraoperative Rupture Rates in 9488 Aneurysms

OBJECTIVE To assess the safety of the suprabrow approach (SBCA) for aneurysm surgery by comparing intraoperative rupture rates with those for the standard pterional approach. METHODS A systematic review of all literature published in or after 1997 was performed using specified search words. All articles described aneurysm surgery by one of two approaches--pterional or suprabrow--and mentioned the rate of intraoperative rupture. A total of 41 articles were found fit for inclusion for the final analysis. Articles that focused on giant, bilateral, posterior fossa, or previously coiled aneurysms were not included. The χ(2) test was used to compare the two cohorts and various subgroup analyses were carried out. A P value of <0.05 was considered significant. RESULTS The search of literature yielded 9488 aneurysm reports (41 articles), 7535 operated by the pterional approach and 1953 aneurysms by the SBCA. The overall intraoperative rupture (IOR) rate for the entire group was 9.20%. In the pterional craniotomy approach (PtCA) group, the rate of IOR was 10.09% and in the SBCA group, IOR occurred in 5.78%. The IOR rate in the PtCA group was almost double that in the SBCA group and the odds ratio (OR) for this difference was 1.8 (95% confidence interval [CI] 1.49-2.26; P< 0.001). A total of 3039 ruptured aneurysms were analyzed--2848 aneurysms in the PtCA group and 191 in the SBCA group. The rate of IOR was 14.15% for the overall group, 13.8% in the PtCA group, and 19.37% in the SBCA group. The difference in IOR between the PtCA group and the SBCA group for ruptured aneurysms was found to be significant (OR 1.5, 95% CI 1.003-2.119; P< 0.05). The number of unruptured aneurysms in the PtCA group was 862 (39.4%) and in the SBCA group, it was 232 (49.1%). The difference in the number of unruptured aneurysms between the groups was significant (P< 0.001). The rate of IOR was significantly less with the SBCA than with the pterional approach. CONCLUSIONS The rate of intraoperative rupture is significantly higher when ruptured aneurysms are operated with the SBCA (in comparison to the pterional approach). However, the SBCA may be safer for unruptured and middle cerebral artery aneurysms with a lower rate of IOR.

Extracranial Infrasellar Ectopic Craniopharyngioma: A Case Report and Review of the Literature

We present a case of a purely infrasellar craniopharyngioma that initially presented as a sphenoid sinus mass. Craniopharyngiomas are usually located within the sella. Purely infrasellar craniopharyngiomas have only rarely been reported in the literature. A 25-year-old woman presented with 6-month history of progressive headaches. Initial neuroimaging revealed the presence of a sphenoid sinus mass. Initially, she underwent an endoscopic biopsy of the mass by our ENT service. Pathology was consistent with craniopharyngioma and she was referred to neurosurgery for further surgical management. She then underwent an endoscopic transsphenoidal approach for complete resection of the purely extracranial, infrasellar craniopharyngioma. The Rathke pouch arises from the roof of the primitive mouth and grows toward the brain at the fourth week of gestation. Normally, it loses its attachment with the stomadeum completely by the eighth week of gestation. The craniopharyngeal canal (CPC) extends from the floor of the sella to the vomer and may rarely give rise to ectopic craniopharyngiomas. This case shows that such ectopic tumors may arise anywhere along the CPC. Endoscopic endonasal approach provides an excellent route for the resection of these tumors.

Treatment of phenylketonuria-associated tremor with deep brain stimulation : Case report

OBJECTIVE AND IMPORTANCE:Phenylketonuria (PKU) is an inborn error of metabolism that causes severe neurological impairment, despite dietary treatment. We present a case of PKU-induced cerebellar tremor treated with deep brain stimulation. There have been no previously reported cases of a patient with a PKU tremor treated with deep brain stimulation. CLINICAL PRESENTATION:A 36-year-old male patient with PKU presented with signs of cerebellar disease including dysmetria, resting tremor, and intention tremor in the left upper extremity. INTERVENTION:A deep brain stimulation electrode was placed in the ventral intermediate nucleus of the right thalamus. CONCLUSION:Immediately after surgery, the patient had nearly complete resolution of intention tremor in the left arm. His resting tremor in the left hand was also greatly improved. The 30-month follow-up examination revealed maintenance of the immediate postoperative improvement.

Unruptured intracranial aneurysms: Comparison of perioperative complications, discharge disposition, outcome, and effect of calcification, between clipping and coiling: A single institution experience

OBJECTIVE The aim of the study was to compare the perioperative complications, obliteration rates, discharge dispositions, clinic-radiological outcomes, and the role of calcification between the microsurgical and endovascular treatment of unruptured intracranial aneurysms. MATERIALS AND METHODS Retrospective data of the patients treated with microsurgical clipping and those treated by endovascular coiling from January 2007 to August 2012 was collected from the database. RESULTS Intraoperative rupture was not different in both the treatment groups (4.05% vs. 1.5% clip vs. coil). A total of 9.4% of the patients in the clipping group and 4.5% of the patients in the coiling group suffered postoperative stroke. At last follow up, 89% of the patients in the clipping group and 93% of the patients in the coiling group had favorable outcomes. The mean length of stay was more in clipping group (6.1 vs. 2.7, clip vs. coil, P < 0.05). Patients discharged to home without assistance/rehabilitation services were more in coiling ( P = 0.001). A total of 28.4% (23/81) of the coiled aneurysms were found to have residue neck on postoperative angiograms as compared with 12.6% (10/79) of the clipped aneurysms ( P = 0.01). Calcification within the aneurysm was strongly correlated to the size, perioperative complications, and the outcome ( P < 0.05). However, on excluding the calcified cases the size and outcome do not show a significant correlation. CONCLUSION With appropriate patient selection, the majority of the UIAs can be managed by either of the treatment modalities with very low mortality and morbidity. Both the treatment modalities should be employed synergistically.

The Utility of Bone Cement to Prevent Lead Migration With Minimally Invasive Placement of Spinal Cord Stimulator Laminectomy Leads

BACKGROUND Lead migration is a significant concern with spinal cord stimulator (SCS) placement with rates ranging from 10% to 60%. OBJECTIVE To describe a novel technique using bone cement at the laminotomy site to help prevent lead migration after minimally invasive placement of laminectomy paddle leads and to present our short-term results. METHODS A review of a prospectively maintained database identified all patients who underwent minimally invasive placement of laminectomy leads with the use of bone cement. All procedures were performed between July 2008 and August 2010 with conscious sedation and local anesthetic. Intraoperative testing was performed to confirm good pain coverage. A small volume of bone cement (1-3 cm) was then placed to cover the laminectomy defect. Radiographic and clinical follow-up was assessed. RESULTS Forty-two patients (mean age, 58.0 years) underwent 42 procedures. Back pain (88.1%) and leg pain (88.6%) were the most common presenting symptoms. No intraoperative complications were noted. Two patients (4.8%) required removal of their devices because of nonhealing wounds. All patients were followed up for a minimum of 6 months, and no cases of clinical or radiographic lead migration were seen at the time of publication. CONCLUSION We present a novel technique in the hopes of decreasing the incidence of lead migration after minimally invasive placement of spinal cord stimulator laminectomy paddle leads. Our results have been promising thus far with no cases of lead migration.

Penetrating foreign body to the cranial vault in a young child

Abstract We present a case of penetrating trauma with a blunt object to the calvarium of a young child. Presentation, emergency room management, radiology, and surgical treatment are illustrated and discussed. It is of utmost importance in these cases to proceed in a way so as to minimize secondary injury that may be caused in removal of the foreign body.

Spinal Arteriovenous Lesions

Spinal arteriovenous lesions represent a heterogeneous set of pathologic entities. As our general understanding of these lesions has evolved, so have the classification systems clini‐ cians use to describe them. Historically, the most common classification of arteriovenous fistulas (AVF) has been the Type I-IV classification. More recently these lesions have been described from an anatomical and physiologic perspective.

When Is Posterolateral Orbitotomy Useful in a Pterional Craniotomy? A Morphometric Study.

Adding posterolateral orbitotomy to pterional craniotomy allows greater exposure of the anterolateral skull base. However, there is a paucity of literature quantifying the relative benefit of adding posterolateral orbitotomy for various surgical targets. Our study is a step to address this issue. We performed dissections of five cadaveric heads (10 sides). The anterior communicating artery (A-Com) complex, posterior chiasm (anterior third ventricular region), ipsilateral optic canal, and ipsilateral supraclinoid internal carotid artery (ICA) bifurcation were chosen as targets. A pterional craniotomy was performed and the targets were morphometrically analyzed. Subsequently, posterolateral orbitotomy was done and analysis repeated. The field of view and measurements quantifying the angle of attack were compared. Addition of orbitotomy to pterional craniotomy increased the angle of exposure to ICA bifurcation, anterior third ventricular region, and A-Com complex by average of 15%, 29%, and 50%, respectively. Our study shows the addition of a posterolateral orbitotomy to the pterional craniotomy improves the angle of attack to the anterior third ventricular region and the A-Com complex, thus supporting the use of orbitopterional craniotomy for suprasellar lesions extending into anteroinferior third ventricle and A-Com aneurysms that point superiorly/posteriorly.