Julius M. Goodman

Confirmation of brain death with portable isotope angiography: a review of 204 consecutive cases

Intravenous isotope angiography is a rapid, safe, and specific bedside test for confirming brain death by demonstrating the lack of critical cerebral perfusion that occurs in this condition, regardless of etiology. A review of 204 consecutive cases of suspected brain death studied with isotope angiography has reaffirmed our confidence in the specificity of the technique and has convinced us to make less stringent our radiographic criteria for confirming brain death by this method. A technically satisfactory single flow study that shows arrest of the carotid circulation at the base of the skull and absence of the intracranial arterial circulation may be considered confirmatory of a carefully established clinical diagnosis of brain death, even though there may be some visualization of the intracranial venous sinuses. Arbitrary waiting periods, withdrawal of sedative drugs, and electrophysiological studies are not needed when this technique is used.

The natural history of untreated skull base meningiomas

BACKGROUND This study was undertaken to determine the natural history of untreated skull base meningiomas. Although there are reports on the natural history of meningiomas, most series contain only a few cases of meningiomas involving the skull base. Natural history information is important when recommending treatment and evaluating results. METHODS The case records and imaging studies of 40 patients with skull base meningiomas from a single practice were reviewed. These patients either did not receive treatment or there was a long delay from the onset of symptoms to the initiation of treatment. RESULTS Skull base meningiomas may be very indolent tumors. Patients with these tumors have lived long, comfortable, and relatively productive lives without treatment or with delayed treatment. Impairment may be much less than imaging studies would suggest. CONCLUSION The authors are not advocating that skull base meningiomas not receive treatment. However, their unique experience with this group of patients provides convincing evidence that the indolent behavior of some skull base meningiomas must be considered when recommending various surgical and radiation procedures and interpreting their results in relationship to the functional outcome of the patient.

Results, outcomes, and follow-up of remnants in the treatment of ophthalmic aneurysms: a 16-year experience of a combined neurosurgical and endovascular team.

OBJECTIVEOphthalmic aneurysms present unique challenges to a vascular team. This study reviews the 16-year experience of a multidisciplinary neurovascular service in the treatment, complications, outcomes, and follow-up of patients with ophthalmic aneurysms from 1990 to 2005. METHODSA retrospective analysis of prospectively collected data of 134 patients with 157 ophthalmic aneurysms is presented. Subgroup analysis is performed based on treatment and clinical presentation of the patients. RESULTSClinical outcomes are reported using the Glasgow Outcome Scale. A “good” outcome is defined as a Glasgow Outcome Scale score of 4 or 5, and a “poor” outcome is defined as a Glasgow Outcome Scale score of 1 to 3. Outcome was related to patient age (P = 0.0002) and aneurysm size (P = 0.046). Outcomes for patients with ruptured aneurysms were related to hypertension (P < 0.0001) and clinical admission grade (P = 0.001). In patients with unruptured aneurysms, a good clinical outcome was noted in 103 (92.7%) of 111 patients at discharge and 83 (94.3%) of 88 patients at the time of the 1-year follow-up evaluation. Complete clipping was attained in 89 (79.5%) of 112 patients with angiographic follow-up. Patients with aneurysm remnants from both coiling and clipping had a low risk of regrowth, and there were no rehemorrhages. One of 25 patients with angiographic follow-up (average, 4.3 ± 4.1 years) after “complete” clipping showed recurrence of the aneurysm. CONCLUSIONDespite the difficulties presented by ophthalmic aneurysms, these lesions can be successfully managed by a multidisciplinary team. Imaging follow-up of patients is important, as there is a risk of aneurysm regrowth after either coiling or clipping.

Endovascular retrograde suction decompression as an adjunct to surgical treatment of ophthalmic aneurysms: analysis of risks and clinical outcomes.

OBJECTIVE Endovascular retrograde suction decompression with balloon occlusion of the internal carotid artery is a useful adjunct in the surgical treatment of ophthalmic aneurysms. This technique helps establish proximal control, facilitates intraoperative angiography, and may aid dissection by evacuating blood and softening the aneurysm. Although the technical aspects of this procedure have been described, the published data on its safety are scant. This study analyzed 2 groups of patients who underwent craniotomies for treatment of ophthalmic aneurysms, comparing a group who received suction decompression with a group who did not. METHODS A retrospective analysis of prospectively collected data on 118 craniotomies for ophthalmic aneurysms performed from 1990 to 2005 is presented. A group of 63 patients treated with endovascular suction decompression during surgery is compared with 55 patients who did not undergo this technique. RESULTS In our overall analysis of ophthalmic aneurysms, the clinical outcome was statistically related to aneurysm size (P = 0.046). The endovascular suction decompression group in this study had overall larger aneurysms (P < 0.0001) compared with the other group. There was no statistical difference between the 2 groups in rates of complications, stroke, new visual deficit, or death. The clinical outcomes were statistically similar at discharge and at 1 year. CONCLUSION Endovascular balloon occlusion and suction decompression did not increase the complication rate in a large cohort of craniotomy patients with ophthalmic aneurysms. This technique may be used to augment surgical capabilities without significantly increasing the operative risk.

Angiographic Assessment of Occipital Encephaloceles

Abstract Previously utilized means of assessment of occipital encephaloceles are of limited value in defining the anatomy of the sac contents, determination of surgical candidates, and prognosis. Posterior fossa angiography has been utilized in 4 cases. It was helpful in determining the neural contents of the sac and particularly brain-stem positioning as judged from angiographic visualization of the basilar artery. Variability of the basilar artery ranging from normal to complete extracranial positioning is shown. Surgical candidacy and prognosis have been ascertained by the angiographic anatomy.

Intrasellar ependymoma: Clinical, imaging, pathological, and surgical findings

Ependymomas arising in the intrasellar compartment are extremely rare and most often are not included in the differential diagnosis of an intrasellar tumor mass. We review the literature to further advance awareness regarding unusual presentations of this type of tumor and present an illustrative case of an intrasellar cystic ependymoma that developed in an uncommon location. In our illustrative case, the patient had a 2 year history of hypopituitarism, but no headaches or visual disturbance. Preoperatively, the lesion was thought to be a pituitary macroadenoma.

Paradoxic appearance of calcification on MRI.

This 37-year-old male with a l-year history of partial complex seizures presented with a major motor seizure. Emergency magnetic resonance imaging (MRl) scan revealed a large right medial temporal lobe mass with bright areas of T, signal suggestive of hemorrhage (Figure 1). The patient had no focal neurologic signs and clinically did not appear to have had a hemorrhage. Subsequent computed tomography (CT) scan showed close correspondence of calcium to the areas of bright T, signal (Figure 2).

Intrasellar pilocytic astrocytomas: Clinical, imaging, pathological, and surgical findings

A pilocytic astrocytoma is not usually considered in the differential diagnosis of an intrasellar tumor. An awareness of this tumor as primarily an intrasellar entity is important to avoid confusion during its diagnosis. We retrospectively examined the records of 631 patients treated at our institution between 2006 and 2010 who underwent transsphenoidal resection of pituitary tumors and identified those diagnosed with pilocytic astrocytoma. We excluded patients who harbored a pituicytoma. We also searched the literature for patients with a histologically confirmed diagnosis of intrasellar pilocytic astrocytoma. Only two patients in our series harbored intrasellar tumors and had a histologic diagnosis of pilocytic astrocytoma. We also found two other cases in the literature that met our criteria. Pilocytic astrocytoma should be considered in the differential diagnosis of an intrasellar lesion. An understanding of this tumors radiological features can avoid diagnostic confusion.

Validity of Radionuclide Cerebral Angiography for Diagnosing Brain Death in Infants

Since 1969, we have been using intravenous (IV) radionuclide cerebral angiography (RCA) as a confirmatory test for brain death in both children and adults (Goodman and Heck, 1977; Goodman et al., 1969, 1985). However, a recent highly respected consensus report (Report of the Medical Consultants on the Diagnosis of Death, 1981) has advised caution in using adult-based criteria for determining brain death in children, implying that a young child with a severe neurological insult may have greater recovery potential than an adult in a similar situation. In order to respond to concerns raised about the validity of RCA in diagnosing brain death in very young patients, we have reviewed our recent results with this technique in infants under 2 years with suspected brain death.