Jared Knopman

Safety and maximum tolerated dose of superselective intraarterial cerebral infusion of bevacizumab after osmotic blood-brain barrier disruption for recurrent malignant glioma. Clinical article.

OBJECTnThe authors assessed the safety and maximum tolerated dose of superselective intraarterial cerebral infusion (SIACI) of bevacizumab after osmotic disruption of the blood-brain barrier (BBB) with mannitol in patients with recurrent malignant glioma.nnnMETHODSnA total of 30 patients with recurrent malignant glioma were included in the current study.nnnRESULTSnThe authors report no dose-limiting toxicity from a single dose of SIACI of bevacizumab up to 15 mg/kg after osmotic BBB disruption with mannitol. Two groups of patients were studied; those without prior bevacizumab exposure (naïve patients; Group I) and those who had received previous intravenous bevacizumab (exposed patients; Group II). Radiographic changes demonstrated on MR imaging were assessed at 1 month postprocedure. In Group I patients, MR imaging at 1 month showed a median reduction in the area of tumor enhancement of 34.7%, a median reduction in the volume of tumor enhancement of 46.9%, a median MR perfusion (MRP) reduction of 32.14%, and a T2-weighted/FLAIR signal decrease in 9 (47.4%) of 19 patients. In Group II patients, MR imaging at 1 month showed a median reduction in the area of tumor enhancement of 15.2%, a median volume reduction of 8.3%, a median MRP reduction of 25.5%, and a T2-weighted FLAIR decrease in 0 (0%) of 11 patients.nnnCONCLUSIONSnThe authors conclude that SIACI of mannitol followed by bevacizumab (up to 15 mg/kg) for recurrent malignant glioma is safe and well tolerated. Magnetic resonance imaging shows that SIACI treatment with bevacizumab can lead to reduction in tumor area, volume, perfusion, and T2-weighted/FLAIR signal.

Spontaneous heparin-induced thrombocytopenia syndrome: 2 new cases and a proposal for defining this disorder

The existence of spontaneous heparin-induced thrombocytopenia (HIT) syndrome (or autoimmune HIT), defined as a transient prothrombotic thrombocytopenic disorder without proximate heparin exposure serologically indistinguishable from HIT, is controversial. We describe 2 new cases presenting with thrombotic stroke/thrombocytopenia: one following shoulder hemi-arthroplasty (performed without heparin) and the other presenting to the emergency room without prior hospitalization, heparin exposure, or preceding infection. Both patients tested strongly positive for anti-platelet factor 4 (PF4)/heparin immunoglobulin (Ig)G in 2 different immunoassays and in the platelet serotonin-release assay. Crucially, both patients sera also caused strong (>80%) serotonin release in the absence of heparin, a serologic feature characteristic of delayed-onset HIT (ie, where heparin use precedes HIT but is not required for subsequent development or worsening of thrombocytopenia). We propose that a rigorous definition of spontaneous HIT syndrome should include otherwise unexplained thrombocytopenia/thrombosis without proximate heparin exposure and with anti-PF4/heparin IgG antibodies that cause strong in vitro platelet activation even in the absence of heparin.

Operative results and learning curve: microscope-assisted tubular microsurgery for 1- and 2-level discectomies and laminectomies

OBJECTnThe authors present their clinical results and the learning curve associated with the use of tubular retractors for 1- and 2-level lumbar microscope-assisted discectomies and laminectomies.nnnMETHODSnThe study involves a retrospective and prospective analysis of 230 patients who underwent noninstrumented minimally invasive procedures for degenerative lumbar spinal disease between 2004 and 2007. Data on patient demographic characteristics and operative results, including length of stay, blood loss, operative times, and surgical complications were collected. Clinical outcomes were assessed based on pre- and postoperative Visual Analog Scale scores, Oswestry Disability Index values, and the Macnab outcome scale scores.nnnRESULTSnThe results showed characteristic differences in blood loss and operating times between 1- and 2-level procedures and between discectomies and laminectomies. A significant learning curve was seen by a decrease in operating time for 1-level discectomies and 2-level laminectomies. Major complications were not observed.nnnCONCLUSIONSnThe use of tubular retractors for microsurgical decompression of degenerative spinal disease is a safe and effective treatment modality. As with other techniques, minimally invasive procedures are associated with a significant learning curve. As surgeons become more comfortable with the procedure, its applications can be expanded to include, for example, spinal instrumentation and deformity correction.

Endoscopy-assisted removal of periorbital inclusion cysts in children

OBJECTnSurgical treatment for periorbital inclusion cysts typically involves a brow, pterional, or partial bicoronal scalp incision for sufficient exposure. The authors have recently employed an endoscopy-assisted technique as an alternative approach intended to minimize the length of the skin incision and avoid scarring in the brow.nnnMETHODSnChildren having typical clinical findings of a dermoid cyst located on the hairless forehead were selected to undergo endoscopy-assisted cyst removal. For suspected intradiploic lesions, MR imaging was used to assess osseous involvement. After induction of general anesthesia, a 1-2-cm curvilinear incision was made posterior to the hairline. A 30°-angled endoscope (4 mm) was then used for dissection in the subgaleal compartment. Subgaleal dissection was followed by a circumferential periosteal incision in which the authors used an angled needle-tip unipolar cautery. For lesions within the diploe, a high-speed air drill was used to expose the lesion. Complete removal was accomplished with curettage of either the skull or dural surface.nnnRESULTSnEight patients (5-33 months of age) underwent outpatient endoscopic resection. Seven cysts were extracranial, and 1 cyst extended through the inner table. In all patients complete excision of the cyst was achieved. There was negligible blood loss, no dural violation, and no postoperative infection. There have been no recurrences at a mean follow-up of 15 months.nnnCONCLUSIONSnEndoscopy-assisted resection of inclusion cysts of the scalp and calvaria is a safe and effective surgical approach. The technique results in negligible incisions with less apparent scarring compared with previously described incisions. This limited-access technique does not appear to be associated with a higher incidence of cyst recurrence.

Combined Supraciliary and Endoscopic Endonasal Approach for Resection of Frontal Sinus Mucoceles: Technical Note

OBJECTIVEnMucoceles are progressive, slow-growing lesions of the paranasal sinuses that, left untreated, can erode into surrounding structures. Complete obliteration and exenteration of the frontal sinus via a bicoronal skin incision and frontal craniotomy is the standard neurosurgical approach to treat these lesions.nnnTECHNIQUEnWe describe two patients who underwent a combined supraciliary keyhole craniotomy and endonasal endoscopic resection of mucoceles with frontal sinus obliteration. The technique takes advantage of a smaller incision, while preserving adequate visualization and the ability for surgical instrumentation. Through the craniotomy, the frontal sinus mucosa is fully exenterated, the posterior table of the sinus is removed to establish communication with the intracranial space, and the nasal frontal ducts are packed with autologous tissue. The endoscopic endonasal route allows a minimally invasive access to the frontal nasal duct to ensure its blockage from the intracranial compartment. Additionally, the endoscope can be used from above through the supraciliary approach to allow for contralateral frontal sinus exposure and mucosal exenteration.nnnCONCLUSIONnThe combined supraciliary-endoscopic endonasal approach provides a minimally invasive access for the treatment of sinonasal disease with frontal sinus mucoceles that invade the intracranial cavity.

Atraumatic epidural hematoma secondary to a venous sinus thrombosis: a novel finding

Venous sinus thrombosis is a rare entity that usually arises secondary to underlying thrombophilia, neoplasm, head injury, or infection. Tympanic infection accounts for the majority of infectious etiologies, and the sigmoid sinus becomes the likely anatomical site of thrombosis. The authors report a case involving a child with recurrent otitis media who presented with an atraumatic epidural hematoma secondary to sigmoid sinus thrombosis. Intraoperative evaluation revealed epidural hemorrhage that originated from the venous sinus, with hemorrhagic products of varying ages. To the authors knowledge, this is the first reported case of a venous sinus thrombosis resulting in an epidural hematoma.

Middle Meningeal Artery Embolization as Treatment for Chronic Subdural Hematoma: A Case Series

BACKGROUNDnTraditional treatment for symptomatic subdural hematoma (SDH) has been surgical evacuation, but recurrence rates are high and patients often harbor complex medical comorbidities. Growth and recurrence is thought to be due to the highly friable nature of the vascularized membrane that forms after initial injury. There have been reported cases of middle meningeal artery (MMA) embolization for treatment of recurrent SDH after surgical evacuation with the goal of eliminating the arterial supply to this vascularized membrane.nnnOBJECTIVEnTo present the first known case series of MMA embolization as upfront treatment for symptomatic chronic SDHs that have failed conservative management in lieu of surgical evacuation.nnnMETHODSnFive patients with symptomatic chronic SDHs underwent MMA embolization using PVA microparticles at our institution. Size of SDH was recorded in maximum diameter and total volume.nnnRESULTSnFour patients underwent unilateral and 1 underwent bilateral MMA embolization successfully. All cases had significant reduction in total volume of SDH at longest follow-up scan: 81.4 to 13.8 cc (7 wk), 48.5 to 8.7 cc (3 wk), 31.7 and 88 to 0 and 17 cc (14 wk, bilateral), 79.3 to 24.2 cc (8 wk), and 53.5 to 0 cc (6 wk). All patients had symptomatic relief with no complications. Histologic analysis of the chronic SDH membrane in a separate patient that required surgery revealed rich neovascularization with many capillaries and few small arterioles.nnnCONCLUSIONnMMA embolization could present a minimally invasive and low-risk initial treatment alternative to surgery for symptomatic chronic SDH when clinically appropriate.

Topical vancomycin to reduce surgical-site infections in neurosurgery: Study protocol for a multi-center, randomized controlled trial

Surgical-site infections (SSIs) account for 20% of all healthcare-associated infections, are the most common nosocomial infection among surgical patients, and are a focus of quality improvement initiatives. Despite implementation of many quality care measures (e.g. prophylactic antibiotics), SSIs remain a significant cause of morbidity, mortality, and economic burden, particularly in the field of neurosurgery. Topical vancomycin is increasingly utilized in instrumented spinal and cardiothoracic procedures, where it has been shown to reduce the risk of SSIs. However, a randomized controlled trial assessing its efficacy in the general neurosurgical population has yet to be done. The principle aim of Topical Vancomycin for Neurosurgery Wound Prophylaxis (NCT02284126) is to determine whether prophylactic, topical vancomycin reduces the risk of SSIs in the adult neurosurgical population. This prospective, multicenter, patient-blinded, randomized controlled trial will enroll patients to receive the standard of care plus topical vancomycin, or the standard of care alone. The primary endpoint of this study is a SSI by postoperative day (POD) 30. Patients must be over 18years of age. Patients are excluded for renal insufficiency, vancomycin allergy, and some ineligible procedures. Univariate analysis and logistic regression will determine the effect of topical vancomycin on SSIs at 30days. A randomized controlled trial is needed to determine the efficacy of this treatment. Results of this trial are expected to directly influence the standard of care and prevention of SSIs in neurosurgical patients.

Perimesencephalic hemorrhage with negative angiography: case illustration

submitted November 4, 2014. accepted December 9, 2014. iNclude wheN citiNg Published online May 29, 2015; DOI: 10.3171/2014.12.JNS142513. disclosure The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. correspoNdeNce Peter Morgenstern, Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, 525 E. 68th St., Box 99, New York, NY 10065. email: pfmorgenstern@gmail.com. A 44-year-old woman presented with headache and perimesencephalic subarachnoid hemorrhage (PM-SAH). Initial dig ital subtraction angiography (DSA) and CT angiography (CTA) showed no underlying pathology (Fig. 1A). On Day 9 DSA revealed a 1.7mm aneurysm of the basilar trunk (Fig. 1B), but CTA on Day 14 failed to demonstrate this aneurysm. The aneurysm was clipped via a subtemporal craniotomy. Postoperative DSA confirmed no residual filling (Fig. 1C), and the patient recovered well. PM-SAH portends a better prognosis and lower probability of aneurysmal pathology and recurrent hemorrhage than aneurysmal SAH. Aneurysms can be found in PM-SAH but are typically identified on initial DSA or CTA.1 Some argue that a single angiographic evaluation is sufficient in patients with PM-SAH. Small aneurysms are found in few patients and disappear on follow-up studies,5 suggesting that identification of the aneurysm may not confer a benefit. This information and concurrent improvements in the sensitivity of CTA have prompted some to consider replacing DSA with CTA in cases of PM-SAH and eliminating repeat studies.3 Advocates of this approach cite unnecessary risks of DSA and radiation exposure in the setting of a “benign” hemorrhage pattern. This case illustrates that a negative DS angiogram does not definitively exclude aneurysmal etiology in PM-SAH. Furthermore, we recommend a conservative approach, utilizing rotational 3D DSA on initial and repeat studies to identify small intracranial aneurysms. This modality remains slightly more sensitive than CTA and conventional DSA at this time.2,4 Prospective studies are needed to ascertain whether detection and treatment of these aneurysms confer a benefit. Perimesencephalic hemorrhage with negative angiography: case illustration

Acute orthostatic headache and diplopia due to a spinal subarachnoid haemorrhage.

A 63-year-old not obese male with negative past medical history presented with acute orthostatic headache and diplopia. Neurological examination upon admission showed bilateral mild abducens palsies. Repeated brain CT scans and MRIs were negative for intracranial pathologies. During hospitalization, headache was partially controlled with analgesics. However, 2 days after admission, the patient endorsed intermittent lower extremity weakness. Therefore, a spine MRI was performed and showed an extramedullary intradural T1wi hyperintense, T2wi isointense image at the T9–T12 level, suggestive for a subacute subarachnoid haemorrhage (Fig. 1). A spinal angiography was then performed and showed a fusiform aneurysm of the ascending left-T11 posterior radicular artery directly supplying a posterior spinal artery, which precluded endovascular embolization (Fig. 2a). A T10-11 laminectomy was therefore performed and the parent artery ligated and divided (Fig. 3). Post-operative angiography confirmed aneurysmal obliteration (Fig. 2b). The patient recovered completely by 6-month follow-up.