Carl Hardwidge

Malignant transformation of acoustic neuroma/vestibular schwannoma 10 years after gamma knife stereotactic radiosurgery.

Only a handful of cases of de-novo malignancies of the vestibulocochlear nerve have been reported. Even rarer is the malignant transformation of a previously histologically diagnosed benign vestibular schwannoma. We present the case of a young adult who had combined operative/Gamma knife treatment for a benign vestibular schwannoma, followed by further surgery 2 years later. He represented 10 years after original diagnosis with facial numbness and ataxia, MRI showing gross tumor recurrence. After radical resection, histology showed malignant transformation to a malignant peripheral nerve sheath tumor. Within 3 months there was rapid, aggressive recurrence with brainstem compression, requiring further surgery for brainstem decompression. Histology confirmed further de-differentiation to an anaplastic sarcoma. While awaiting radiotherapy the tumor recurred again, the patient succumbing. The patient had no features of neurofibromatosis type 2. In the literature there are 13 other cases of malignant vestibular schwannomata. Only six had radiotherapy and of these only two had histological confirmation of a benign lesion preradiotherapy. Neither of these had neurofibromatosis. Three other cases had histological proof of malignancy postradiosurgery, but with no preradiotherapy histology; of these, two were positive for neurofibromatosis. The tumor biology of vestibular schwannomata as well as the radiobiology in the context of malignant transformation is discussed.

Penetrating civilian craniocerebral gunshot wounds: a protocol of delayed surgery

OBJECTIVE:Several factors have led to our unique approach of delayed definitive débridement. We wanted to evaluate the effectiveness of our management and compare it with the existing data in the literature. METHODS:We retrospectively reviewed the records of 194 patients presenting between January 1996 and October 2003 with penetrating craniocerebral gunshot wounds. After exclusion criteria, 125 patients qualified. RESULTS:Of the patients, 88.8% were male. The mean age was 24.9 ± 10.9 years. In 70.4% of patients, the presenting Glasgow Coma Scale (GCS) score was 3 to 8. Only 38 (30.4%) of the 125 patients survived, with poor outcome in 2 and good outcome in 36. Bilaterally fixed and dilated pupils and bihemispheric tract on computed tomographic scan were significantly related to poor outcome. There were 49 surgical procedures performed on 27 of the patients, with a mortality rate of 7.4%. Of the 38 survivors, 13 underwent no surgery. Average time to surgery was 11.04 days. Total rate of infection was 8%, and it did not influence outcome. No patient presenting with a GCS score of 3 or 4 survived. Seventeen patients attended follow-up, for a total of 3609 days (average, 212 d) and very few late complications. CONCLUSION:Our supportive care of patients is not optimal. We should have saved more of our patients who presented with GCS scores of 14 and 15 who subsequently died. We have been able to report unconventionally late surgical management of two-thirds of survivors, with no surgery in one-third of survivors. Despite a high rate of infectious complications, infection did not lead to death or disability. Our protocol rarely leads to patients surviving in a permanently vegetative state. In the future, we would perform early surgery for patients who present awake and continue our current management for poor-grade patients. In this way, we will improve the number of good outcomes without increasing the population of severely damaged and dependent survivors.

The management of cerebellar abscess since the introduction of CT scanning

Sixteen patients with surgical infection of the posterior fossa are presented. There were 14 patients with cerebellar abscess, one patient with a solitary posterior fossa subdural empyema, and another with a combined cerebellar abscess and subdural empyema. Two of the cerebellar abscess patients also had supratentorial infections. The presenting features, aetiology, radiology and bacteriology are discussed with particular reference to differences in abscess re-accumulation, and outcome between those managed by aspiration and excision. We have been unable to show that either method of treatment is superior to the other. An overall mortality rate of 19% was achieved; however, for those with parenchymal cerebellar abscesses this was reduced to 13%. We conclude that burr hole aspiration with regular CT is a satisfactory method of treatment for cerebellar abscess.

Pyomyelia: an intramedullary spinal abscess complicating lumbar lipoma with spina bifida

We report a case of spinal dysraphism, complicated by an intramedullary spinal abscess (IMSA). The magnetic resonance images of this case are shown and the pathophysiology of this condition is discussed.

Are internet sites providing evidence-based information for patients suffering with Trigeminal Neuralgia?

Trigeminal neuralgia has a variety of treatments with variable efficacy. Sufferers present to a spectrum of disciplines. While traditional delivery of medical information has been by oral/printed communication, up to 50–80% patients access the internet for information. Confusion, therefore, may arise when seeking treatment for trigeminal neuralgia. We evaluated the quality of information on the internet for trigeminal neuralgia using the DISCERN© instrument. Only 54% websites had clear objectives; 42% delivered on these. A total of 71% provided relevant information on trigeminal neuralgia, 54% being biased/unbalanced; 71% not providing clear sources of information. No website detailed the side-effect profile of treatments; 79% did not inform patients of the consequences/natural history if no treatment was undertaken; it was unclear if patients could anticipate symptoms settling or when treatment would be indicated. Internet information on trigeminal neuralgia is of variable quality; 83% of sites assessed were of low-to-moderate quality, 29% having ‘serious shortcomings.’ Only two sites scored highly, only one being in the top 10 search results. Websites on trigeminal neuralgia need to appreciate areas highlighted in the DISCERN© instrument, in order to provide balanced, reliable, evidence-based information. To advise patients who may be misguided from such sources, neurosurgeons should be aware of the quality of information on the internet.

Re-do microvascular decompression for recurrent trigeminal neuralgia

We read with interest the article from Messrs Ugwuanyi & Kitchen promoting re-do microvascular decompression (MVD) for recurrent trigeminal neuralgia. We were pleased to see the favourable outcomes in terms of their neuralgia. However, we are disappointed as their article gives no indication of the length of stay or the complications encountered in their patient group. Re-do MVD is not a procedure to be undertaken with little hesitation as suggested. There is a real risk involved. When there is a clear residual or a recurrent vascular compression shown on the MRI, then a case can be made for revision surgery. Many cases are not so clear cut. Even for those familiar with the cerebello-pontine angle and performing microvascular decompression regularly, it can be a very challenging operation. The ‘perception of increased risk’ is well documented. Rath et al., 1996, reported that the risk of a revision microvascular decomression ‘was more than twice that of our first MVD procedures’. Kureshi and Wilkins, 1998 reported the increased risk was an indication for considering Rhizotomy and other alternatives. It is also the author’s experience that revision MVD can be less than straight forward. We would suggest that any publication on this topic should include a clear indication of complications and length of stay.

A thoracic extradural chordoid meningioma: a unique case report and literature review

Abstract We describe the unique case of a patient being diagnosed with a thoracic extradural chordoid meningioma following her presentation with mild lower limb pyramidal weakness and a T8 sensory level. This is the first report of an extradural chordoid meningioma being identified in the thoracic spine. The tumour was successfully resected through a posterior thoracic laminectomy approach. Post-operatively, her neurological deficit resolved and to date she has not experienced a radiological recurrence. In this report, we review the literature and discuss this unusual tumour’s characteristics and prognostic significance.

PENETRATING CIVILIAN CRANIOCEREBRAL GUNSHOT WOUNDS

OBJECTIVE Several factors have led to our unique approach of delayed definitive débridement. We wanted to evaluate the effectiveness of our management and compare it with the existing data in the literature. METHODS We retrospectively reviewed the records of 194 patients presenting between January 1996 and October 2003 with penetrating craniocerebral gunshot wounds. After exclusion criteria, 125 patients qualified. RESULTS Of the patients, 88.8% were male. The mean age was 24.9 +/- 10.9 years. In 70.4% of patients, the presenting Glasgow Coma Scale (GCS) score was 3 to 8. Only 38 (30.4%) of the 125 patients survived, with poor outcome in 2 and good outcome in 36. Bilaterally fixed and dilated pupils and bihemispheric tract on computed tomographic scan were significantly related to poor outcome. There were 49 surgical procedures performed on 27 of the patients, with a mortality rate of 7.4%. Of the 38 survivors, 13 underwent no surgery. Average time to surgery was 11.04 days. Total rate of infection was 8%, and it did not influence outcome. No patient presenting with a GCS score of 3 or 4 survived. Seventeen patients attended follow-up, for a total of 3609 days (average, 212 d) and very few late complications. CONCLUSION Our supportive care of patients is not optimal. We should have saved more of our patients who presented with GCS scores of 14 and 15 who subsequently died. We have been able to report unconventionally late surgical management of two-thirds of survivors, with no surgery in one-third of survivors. Despite a high rate of infectious complications, infection did not lead to death or disability. Our protocol rarely leads to patients surviving in a permanently vegetative state. In the future, we would perform early surgery for patients who present awake and continue our current management for poor-grade patients. In this way, we will improve the number of good outcomes without increasing the population of severely damaged and dependent survivors.