Kevin H. Siu

Aggressive surgical treatment of elderly patients following subarachnoid haemorrhage: management outcome results.

This report presents 74 consecutive cases of subarachnoid haemorrhage (SAH) in patients aged 70 years or older, compared with the 317 consecutive younger patients treated during the same period. An ultra-early surgical strategy for all SAH cases was used throughout the study period. Management outcome for all grades of elderly patients was independent in 38%, dependent in 14% and death in 49%. Surgical 3-month outcome of good grade elderly patients was independent 53%, dependent 19% and death 28%; and for poor grades was independent 35%, dependent 15% and death 50%. Elderly poor grade patients had similar outcome to younger patients, although good grade patients had better outcome in the younger group than the elderly group. Despite ultra-early surgery, rebleeding (<12 h of SAH) occurred in 9% of the elderly series. Aggressive, ultra-early treatment is likely to benefit elderly SAH patients, the potential benefit being greater for poor grade elderly patients.

Middle fossa arachnoid cysts in association with subdural haematomas. A review and recommendations for management

Subdural haematomas occur in association with arachnoid cysts. Six cases of subdural haematoma are reported in 18 patients with previously asymptomatic middle fossa arachnoid cysts. A review of this patient population and the literature in respect of pathogenesis and treatment of arachnoid cysts was made. Cysto-peritoneal shunt is recommended as the surgical treatment after evacuation of the haematoma. The aetiology of haematoma formation has not been conclusively described, but may partly result from a high pressure intracranial system with decreased compliance.

Gliosarcoma with osteosarcomatous differentiation: review of radiological and pathological features

Gliosarcoma is a rare tumor of the central nervous system, consisting of gliomatous and sarcomatous elements. We present an unusual case of gliosarcoma which demonstrated a variation in phenotype over a six month period, changing from a gliosarcoma with osteosarcomatous differentiation, to a gliosarcoma with no osteosarcomatous component. The initial histological diagnosis was glioblastoma multiforme. Fifteen months later the tumor had transformed into a gliosarcoma demonstrating osteosarcomatous differentiation, with the majority of the tumor consisting of osteoid matrix. Further samples taken six months later revealed gliosarcoma with almost no osteosarcomatous component. It is recognized that glioblastoma can undergo a change in phenotype, transforming into a gliosarcoma. This case demonstrates that ongoing changes in phenotype can occur, especially when the tumor has been treated with chemotherapy and radiotherapy. An understanding of the pathological progression of gliosarcoma will become increasingly important as novel treatments for gliosarcoma and glioblastoma become available.

Intracranial subdural hematoma after lumbar myelography.

Two cases of intracranial subdural hematoma after lumbar myelography are reported. This complication should be considered in patients who complain of prolonged headache or who develop neurological signs after lumbar puncture.

Subarachnoid haemorrhage due to a dissecting aneurysm of the anterior cerebral artery: a case report.

Dissecting aneurysms of the intracranial carotid circulation are becoming increasingly recognised as a cause of subarachnoid haemorrhage. We present a case where SAH caused by anterior cerebral artery dissection was diagnosed on a repeat angiogram and successfully treated by surgical trapping. Diagnosis may be difficult as angiographic signs may be subtle and variable. Accurate diagnosis and prompt treatment is important, as the re-bleed rate is high.

Intraventricular neurocytoma, a recently recognized pathological entity: Report of two cases and review of the literature

Neurocytoma has only recently been recognized as a distinct pathological entity. Previously a rare tumor, it is now being recognized with increasing frequency. It typically presents in an intraventricular location in young adults. Many neurocytomas were originally diagnosed by light microscopy as oligodendrogliomas. More recently they have been shown to have ultrastructural and immunohistochemical features of neuronal differentiation. This paper presents two cases of intraventricular neurocytomas and reviews the recent literature.

Early surgery for posterior circulation aneurysms following subarachnoid haemorrhage

A retrospective analysis of 32 patients with posterior circulation aneurysms operated on within three days of subarachnoid haemorrhage is presented. The cases were treated at two Australian neurosurgery units over a five year period (1988-1992), both units having a policy of treating patients of all grades and all ages with early surgery. No patients suffered rebleeding. Five patients developed clinical vasopasm. Twenty-four patients (75%) had a good outcome (Glasgow Outcome Score 1-2), three had a poor outcome (GOS 3), and five died (16%). Of the five deaths, three presented as Hunt and Hess grade V. The results are considered in detail and the literature regarding the timing of surgery for posterior circulation aneurysms is reviewed.

Acute atlanto-axial post-operative subluxation following posterior C1/2 fusion

Two cases referred with acute post-operative C1/2 subluxation following posterior fusion are reported. Both cases had initial treatment for atlanto-axial instability with posterior cable (Brooks and interspinous) and graft techniques, and placed immediately in a Philadelphia collar. One case was found to have subluxed immediately post-operatively when failing to breathe following reversal of anaesthetic agents, and despite immediate realignment and reoperation was left with a significant quadriparesis. The other patient was noted to have subluxed on routine X-ray on day 4, and had no neurological deficit before or after reoperation. Risk factors for this dangerous complication are discussed and the techniques of C1/2 posterior fusion and stabilization are reviewed in detail. Surgeons performing atlanto-axial stabilization procedures should be familiar with and have expertize in the complete range of techniques described and choose the one most appropriate for the patients individual requirements.