Brian P. Brophy

Surgical treatment of nocardial brain abscesses

OBJECTIVE Nocardial brain abscesses are associated with significant morbidity and mortality rates. The optimal management remains unclear. We reviewed the surgical outcomes of patients treated with a relatively uniform policy at a single institution. METHODS Eleven patients were treated at the Royal Adelaide Hospital between 1970 and 2001. Their clinical presentations, surgical treatment, and outcomes were reviewed. RESULTS Clinical presentations most frequently involved focal neurological deficits (91%). Predisposing factors were identified for 63% of the patients. Nine patients were treated only with aspiration and long-term chemotherapy. Two patients underwent craniotomy and lesion excision. The majority of patients required either one or two procedures. There were no deaths in this series. Management complications were observed for three patients. Abscess aspiration was complicated by parenchymal hemorrhage and ventriculitis for one patient and temporary worsening of hemiparesis for two patients. CONCLUSION Our results suggest that aspiration alone (repeated as clinically indicated) is a safe, efficacious treatment for the majority of patients with nocardial brain abscesses.

Endoscopic endonasal resection of anterior skull base meningiomas.

Objective Anterior cranial fossa (ACF) meningiomas are difficult to surgically manage. Endoscopic transnasal approaches have increasingly been used as a minimally invasive route and thus offer significant advantages. However, a paucity of literature describing the intraoperative challenges and postoperative outcomes of this technique still exists. Study Design Case series with chart review. Setting The Royal Adelaide Hospital, Flinders Medical Centre, Wellington Hospital. Subjects and Methods Fifteen consecutive patients who underwent endoscopic resection of ACF meningiomas between 2004 and 2010 by the South Australian and Wellington Skull Base Units. Demographic and clinical information was compiled by reviewing patient charts and operation notes. Safety and efficacy of the procedure, role of a team approach, and areas for further improvement were analyzed. Results Of the patients, 87% were women. Tumor locations: 8 olfactory groove, 2 tuberculum sellae, 1 clinoidal, 1 jugum sphenoidale, 1 planum sphenoidale, 1 subfrontal, and 1 midline ACF floor. Commonest presenting symptom was visual change. Mean volume of tumor was 25.69 cm3, with a size area of 7.28 cm2. Five were revision cases. None had previous endonasal surgery. Average operating times decreased over time. Gross total removal was achieved in 14, with no deaths. Four patients had postoperative cerebrospinal fluid (CSF) leak. Rate of CSF leak decreased over time. Sixty percent of patients reported visual improvement. Two patients had radiological evidence of recurrence. Conclusion ACF meningiomas can be safely removed endonasally, offering significant advantages over the traditional transcranial approach for suitable tumors. Early audit of this approach shows results achieved by this unit are comparable with the published literature.

A surgical model of permanent and transient middle cerebral artery stroke in the sheep.

Background Animal models are essential to study the pathophysiological changes associated with focal occlusive stroke and to investigate novel therapies. Currently used rodent models have yielded little clinical success, however large animal models may provide a more suitable alternative to improve clinical translation. We sought to develop a model of acute proximal middle cerebral artery (MCA) ischemic stroke in sheep, including both permanent occlusion and transient occlusion with reperfusion. Materials and Methods 18 adult male and female Merino sheep were randomly allocated to one of three groups (n = 6/gp): 1) sham surgery; 2) permanent proximal MCA occlusion (MCAO); or 3) temporary MCAO with aneurysm clip. All animals had invasive arterial blood pressure, intracranial pressure and brain tissue oxygen monitoring. At 4 h following vessel occlusion or sham surgery animals were killed by perfusion fixation. Brains were processed for histopathological examination and infarct area determination. 6 further animals were randomized to either permanent (n = 3) or temporary MCAO (n = 3) and then had magnetic resonance imaging (MRI) at 4 h after MCAO. Results Evidence of ischemic injury in an MCA distribution was seen in all stroke animals. The ischemic lesion area was significantly larger after permanent (28.8%) compared with temporary MCAO (14.6%). Sham animals demonstrated no evidence of ischemic injury. There was a significant reduction in brain tissue oxygen partial pressure after permanent vessel occlusion between 30 and 210 mins after MCAO. MRI at 4 h demonstrated complete proximal MCA occlusion in the permanent MCAO animals with a diffusion deficit involving the whole right MCA territory, whereas temporary MCAO animals demonstrated MRA evidence of flow within the right MCA and smaller predominantly cortical diffusion deficits. Conclusions Proximal MCAO can be achieved in an ovine model of stroke via a surgical approach. Permanent occlusion creates larger infarct volumes, however aneurysm clip application allows for reperfusion.

The ‘rosette‐forming glioneuronal tumor’ of the fourth ventricle

Tumors containing both neuronal and glial components are a rare heterogeneous group with unique features that require further subclassification. The rosette‐forming glioneuronal tumor of the fourth ventricle is one of a number of recently described glioneuronal tumors, which has been accorded official WHO nosologic status only in 2007. We describe the clinical and pathologic features of two patients with rare rosette‐forming glioneuronal tumors of the fourth ventricle, one of which was associated with dysgenetic tricho‐rhinopharyngeal type I syndrome.

An endoscopic endonasal technique for resection of olfactory groove meningioma

Meningiomas of the olfactory groove have generated a significant amount of discussion in the literature regarding preferred surgical approach. Neuropsychiatric dysfunction is one of the most common presenting symptoms, so surgical approaches have focused on the need to minimize further dysfunction, chiefly by reducing retraction on the frontal lobes. We report a case of olfactory groove meningioma treated with a minimally invasive entirely endoscopic technique. The endoscopic endonasal technique represents a possible alternative for suitably selected cases and could be expected to minimize neuropsychiatric sequelae.

Emergency neurosurgery by general surgeons at a remote major hospital.

Background:  Due to the geographical remoteness of Darwin, which has no resident neurosurgeon, emergency transfer of patients for neurosurgery is usually impractical. In Darwin emergency neurosurgery must be undertaken by general surgeons.

Thalamotomy for Parkinsonian Tremor

Thalamotomy for parkinsonian tremor was performed in 25 patients. A good outcome was achieved in 66% of cases. Three patients sustained a significant new deficit. Stimulation through the lesioning electrode provided an adequate means of corroboration of target localisation.

Blister-like aneurysm of the anterior communicating artery

We report a recent experience with a blister-like aneurysm of the anterior communicating artery and suggest that this entity may be responsible for so-called non-aneurysmal haemorrhage when the distribution of blood is atypical.

Ganglioglioma of the lateral ventricle presenting with blepharospasm : case report and review of the literature

Gangliogliomas of the lateral ventricle are unusual tumours of the central nervous system. We report a 25-year-old female who presented with a 4-week history of generalized headaches associated with left-sided blepharospasm. Clinical examination revealed bilateral papilloedema but no focal neurological deficits. Computed tomography and magnetic resonance imaging demonstrated a large lesion within the left lateral ventricle. Gross total surgical resection of the lesion was performed through a para-sagittal, trans-callosal approach. Histopathological analysis revealed the diagnosis of ganglioglioma. The post-operative course was uneventful, with complete resolution of both the headaches and blepharospasm. The presentation with an ipsilateral blepharospasm has never previously been reported in the setting of a lateral ventricular tumour.

Treatment of multiple arteriovenous malformations in pediatric patients with hereditary hemorrhagic telangiectasia and spontaneous hemorrhage. Report of two cases.

Due to inheritance of an autosomal dominant genetic mutation, patients with hereditary hemorrhagic telangiectasia (HTT) have an increased risk of harboring a cerebral arteriovenous malformation (AVM). They are also significantly more likely to have multiple AVMs. The natural history of AVMs in patients with HHT as well as their rate of hemorrhage is not clearly defined. Furthermore, spontaneous regression of such lesions has been reported. Treatment of cerebral AVMs in patients with HHT presents a particular challenge, especially with detection of incidental lesions following screening of asymptomatic patients. The management of HHT in two pediatric patients in whom hemorrhaging from a cerebral AVM occurred but who also had other lesions is presented here. Both patients were treated with stereotactic radiosurgery.