John C. Godersky

Variables predicting surgical outcome in symptomatic hydrocephalus in the elderly

We prospectively studied 30 older patients who had shunt surgery for symptomatic hydrocephalus and measured outcome using serial videotaping of gait, neuropsychological testing, and the Katz index of activities of daily living. Twenty-three patients improved and 7 did not. Using univariate analysis and the Fisher exact test, we found that the following variables were significantly related to outcome: (1) time B-waves present on 24-hour CSF pressure record; (2) anterior/posterior ratio on slice 4 of regional cerebral blood flow study; (3) duration of dementia prior to surgery; and (4) gait abnormality preceding dementia. The following variables showed a trend towards significance: (1) time CSF pressure > 15 mm Hg; and (2) scoring either pass or fail on the Multilingual Visual Naming Test. We conclude that several variables are significantly associated with surgical outcome in symptomatic hydrocephalus in the elderly and can be used in deciding whether to recommend surgery.

Idiopathic normal pressure hydrocephalus and systemic hypertension

Nineteen patients with idiopathic normal pressure hydrocephalus (NPH) were treated with intraventricular shunts. Ten of the 14 who improved and 14 of the total group had systemic hypertension. The prevalence of hypertension in both the improved and whole NPH groups was significantly greater than in a control group with dementia (N = 122) and the published prevalence of hypertension in the US population for this age group. Four possible mechanisms for this association are discussed.

Intradural extramedullary cysts of the spinal canal: clinical presentation, radiographic diagnosis, and surgical management.

Fourteen patients with intradural extramedullary cysts of the spinal canal are described. Histological classification included 11 arachnoid, 2 epithelial, and 1 ependymal cyst. There were 9 thoracic, 3 cervical, and 2 lumbar cysts. The most common clinical presentation was a slowly progressive myelopathy. Twelve patients (85%) had objective neurological findings at the time of diagnosis. Radiographic diagnosis was made by a combination of myelography, computed tomographic scan with myelography, and magnetic resonance imaging. Complete surgical resection was accomplished for 8 dorsal cysts, and 6 ventral cysts were widely fenestrated into the subarachnoid space. Overall results were considered excellent or good in 9 patients, fair in 3, and poor in 2. There was one recurrence, which required a second operation. We conclude that the majority of intradural spinal cysts can be successfully managed surgically with a favorable clinical outcome.

Use of magnetic resonance imaging in the evaluation of metastatic spinal disease.

Spinal metastases are present in up to 10% of all cancer patients at some time during the course of their disease. Pain is the most common presenting symptom, and neurological function is usually normal at this early stage. The clinical challenge is to detect and treat the spinal disease before the onset of neurological compromise. Myelography has been the standard test for identification of epidural metastases, but the invasive nature of myelography carries inherent risk and produces patient discomfort. Magnetic resonance imaging (MRI) has been useful in the evaluation of other spinal diseases, is noninvasive, and is tolerated well by patients. We evaluated and compared MRI (64 studies in 58 patients) to conventional studies (myelography, computed tomography, bone scanning, plain films) and determined its accuracy in diagnosis and efficacy in clinical decision making. MRI proved superior in detecting bone and epidural involvement by tumor and was valuable in clinical decision making. In addition, MRI provided better visualization of paravertebral soft tissue involvement by tumor. MRI is recommended as the initial study in patients with suspected metastatic spinal disease.

Regional Cerebral Blood Flow in Normal Pressure Hydrocephalus

Regional cerebral blood flow (rcbf) was studied preoperatively and at 2 and 6 months postoperatively in 22 normal pressure hydrocephalus patients using xenon-133 inhalation and single photon emission computed tomography. Sixteen of the 22 patients improved (improved group) and six did not (unimproved group). The following comparisons were made: (1) preoperative rcbf in the improved group, to 14 normal elderly volunteers and to that in 59 SDAT (senile dementia of the Alzheimer type) patients; (2) preoperative rcbf in the improved and unimproved groups to determine if rcbf could predict surgical outcome; (3) pre- to postoperative rcbf in the improved group to see if increased cbf accounted for clinical improvement. The findings were: (1) preoperative rcbf in the improved group was lower than that in normal controls but was the same as that in SDAT; however, the ratios of rcbf values in anterior and posterior brain regions were significantly different between improved group and SDAT (p = 0.02); (2) an anterior/posterior ratio of 1.05 correctly classified surgical outcome in 19/22 patients; five of six in the unimproved group were above this cut off while 14/16 in the improved group were below; (3) in the improved group rcbf increased at 2 but not at 6 months after surgery without a corresponding reduction of clinical signs, supporting the notion that increase in cbf probably does not account for clinical improvement in normal pressure hydrocephalus.

Intraluminal clot of the carotid artery. A clinical-angiographic correlation of nine patients and literature review

Between March 1980 and March 1985, intraluminal thrombi of the carotid artery were noted in 9 of 2250 patients undergoing arteriography for symptoms of cerebral ischemia. Five patients had transient ischemic attacks, and four had acute cerebral infarctions. Six patients had surgery, but a thrombus was only found in five. Two patients had new neurological deficits after surgery. Three patients received only medical therapy, and all remained stable. Intraluminal thrombus is an uncommon radiographic finding in patients with cerebral ischemia. Not all clots are confirmed at operation. The optimal treatment of this situation is not known. Both surgical and medical treatments deserve further investigation.

Brain tumors occurring before 1 year of age: a retrospective reviews of 22 cases in an 11-year period (1977-1987).

Congenital brain tumors have been reported infrequently and their management remains ill defined. An 11-year review (1977-1987) of all children with brain tumors with the onset of symptoms before 1 year of age was completed. Twenty-two children with the following histological diagnoses were treated: astrocytoma (7 patients), primitive neuroectodermal tumor (6 patients), papilloma or carcinoma of the choroid plexus (3 patients), malignant teratoma (2 patients), dermoid tumor (2 patients), embryonal rhabdomyosarcoma (1 patient), and chloroma (1 patient). Fifteen tumors were supratentorial in location, and 7 were infratentorial. Initial symptoms were hydrocephalus (32%), focal neurological deficit (23%), asymptomatic increase in head circumference (18%), failure to thrive (14%), and seizures (4.5%). The goal of treatment was a radical excision when possible, with primary chemotherapy in the last 6 years of the review period. Radiation therapy was the adjunct to surgery in the initial 5-year period. All patients with papillomas of the choroid plexus and dermoid lesions underwent a total resection with no recurrence. All 7 astrocytomas were supratentorial, with 6 occurring in the diencephalon. Five of the seven patients with astrocytomas survived more than 5 years. The 6 primitive neuroectodermal tumors were located equally between the supra- and infratentorial spaces. Four of the 6 infants with these tumors received chemotherapy (2 received chemotherapy alone; 2 received chemotherapy and radiation therapy) and are tumor free 2 to 9 years later. A fifth child received radiation therapy alone early in the series and survived only 4 months. The family of the other child refused adjunctive treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Intradural Extramedullary Cysts of the Spinal Canal

Fourteen patients with intradural extramedullary cysts of the spinal canal are described. Histological classification included 11 arachnoid, 2 epithelial, and 1 ependymal cyst. There were 9 thoracic, 3 cervical, and 2 lumbar cysts. The most common clinical presentation was a slowly progressive myelopathy. Twelve patients (85%) had objective neurological findings at the time of diagnosis. Radiographic diagnosis was made by a combination of myelography, computed tomographic scan with myelography, and magnetic resonance imaging. Complete surgical resection was accomplished for 8 dorsal cysts, and 6 ventral cysts were widely fenestrated into the subarachnoid space. Overall results were considered excellent or good in 9 patients, fair in 3, and poor in 2. There was one recurrence, which required a second operation. We conclude that the majority of intradural spinal cysts can be successfully managed surgically with a favorable clinical outcome.

Surgical experience with cerebral amyloid angiopathy.

Cerebral amyloid angiopathy can present as lobar intracerebral hemorrhage in an elderly person, presumably due to increased fragility of the vessels affected by amyloid deposition. For this reason, patients presenting with intracerebral hemorrhage and suspected of having cerebral amyloid angiopathy have often been treated nonsurgically. Since 1983 we have evaluated 11 patients with cerebral amyloid angiopathy (nine women and two men, mean age 73 years) who have undergone either intracerebral hematoma evacuation or brain biopsy. Nine of the 11 patients presented with intracerebral hemorrhage, which was unilobar in three patients and multilobar in six and involved the parietal lobes seven times, the frontal lobes four times, the temporal lobes four times, and the occipital lobes twice. These nine patients underwent hematoma removal, with no cases of abnormal intraoperative bleeding or recurrent hemorrhage. Six patients improved neurologically, and two were unchanged after hematoma evacuation; the remaining patient had a fatal cardiopulmonary arrest during the immediate postoperative period. During follow-up in seven patients (median 11 months, range 1 week to 74 months) none experienced a recurrent intracerebral hemorrhage and four continued to improve. Two of the 11 patients had cerebral amyloid angiopathy diagnosed by brain biopsy as part of an evaluation for dementia, also without surgical complications. This series suggests that patients with cerebral amyloid angiopathy may safely undergo operative procedures, and patients presenting with intracerebral hemorrhage may show neurologic improvement following evacuation of the hematoma.

A randomized trial of aspirin or heparin in hospitalized patients with recent transient ischemic attacks. A pilot study.

In a randomized pilot study we compared the efficacy of temporary anticoagulation with intravenous heparin sodium to the efficacy of aspirin in preventing cerebral infarction in hospitalized patients with recent (less than 7 days) transient ischemic attacks (TIAs). Fifty-five patients (33 men, 22 women) aged 36-81 (mean 62.7) years met entry criteria and agreed to participate. Symptoms prompting hospitalization were referable to the carotid distribution in 43 patients (34 hemispheric, nine retinal); 12 patients had vertebrobasilar distribution TIAs. Twenty-seven patients received heparin and 28 received aspirin. Patients were treated until surgery or until long-term medical therapy was instituted, 3-9 (mean 5.5) days in the heparin group and 3-15 (mean 5.8) days in the aspirin group. Recurrent TIAs occurred in eight patients given heparin and in seven treated with aspirin. Infarction occurred in one patient in the heparin group and in four patients in the aspirin group (three brain, one retinal infarction). Initial symptoms in these five patients were referable to the carotid distribution in two and to the vertebrobasilar distribution in three. All patients but the one with a retinal infarction had recurrent TIAs prior to stroke. Our pilot study suggests that hospitalized patients with recent TIAs are at high risk for recurrent TIAs (15 of 55, 27%) and brain infarction (five of 55, 9%) and that patients with recent vertebrobasilar distribution TIAs have a marginally significantly higher risk (odds ratio 6.83, 95% confidence interval 0.65-88.66) of infarction than patients with recent carotid distribution TIAs.