Mahmoud G. Nagib

Civilian gunshot wounds to the brain: prognosis and management.

The extent of treatment for the victims of gunshot wounds to the brain remains quite controversial, particularly when these patients present with extensive neurological dysfunction. We propose guidelines regarding the degree and aggressiveness of therapy. The factors that seem to have a significant impact on the patients final outcome are the neurological examination at the time of admission, the radiological findings, and the motivation for the shooting. Thus, the authors propose a nonsurgical line of therapy for comatose patients with unilateral or bilateral cerebral gunshot wounds where bone or metal fragments are visualized away from the bullet path on computed tomography scan, particularly when these individuals are suicide victims.

Klippel-Feil syndrome in children: clinical features and management

A retrospective analysis of 11 children with the diagnosis of Klippel-Feil syndrome treated at the University of Minnesota Hospital over a period of 20 years is presented. The salient features of the syndrome and its associated anomalies are reviewed. Emphasis is placed on its neurological aspects, particularly the potential risks of injury to the craniocervical junction and cervical spine. Guidelines for the management of these patients are suggested.

Tuberous sclerosis: a review for the neurosurgeon.

&NA; The clinical. radiological, and pathological characteristics of tuberous sclerosis are reviewed. Neurosurgical intervention in the syndrome is discussed in light of two recently treated cases and a literature review. (Neurosurgery 14:93‐98. 1984)

Lateral ventricle choroid plexus papilloma in childhood: management and complications

BACKGROUND A review of the choroid plexus papilloma of the lateral ventricle in the pediatric age group is presented. The characteristic clinical features, imaging studies, preoperative, and operative approaches, as well as complications, will be included. METHODS Among a group of 24 patients with ventricular choroid plexus papilloma treated by the authors over a 12-year period, seven patients were selected for this study. The selection included patients under the age of 8 years at the time of their presentation with choroid plexus papilloma of the lateral ventricle. Adult patients and children with choroid plexus papilloma at other sites or choroid plexus carcinoma were excluded. At least a 30-month follow-up period was available for all patients except one. Preoperative and postoperative imaging studies confirming total tumor resection were available for all patients. RESULTS Developmental delays and regression were the most consistent clinical features. Magnetic resonance imaging (MRI) proved to be the diagnostic test of choice. The addition of magnetic resonance angiogram (MRA) obviates the need for angiography. Our attempts at tumor embolization failed. CONCLUSION An intersulcal splitting approach to the lateral ventricular trigone, combined with a perioperative external ventricular drainage, may be of value in the avoidance of symptomatic subdural effusions.

The Initial Use of Free-running Electromyography to Detect Early Motor Tract Injury during Resection of Intramedullary Spinal Cord Lesions

OBJECTIVE: The resection of intramedullary spinal cord lesions (ISCLs) can be complicated by neurological deficits. Neuromonitoring has been used to reduce intraoperative risk. We have used somatosensory evoked potentials (SEPs) and muscle-derived transcranial electrical motor evoked potentials (myogenic TCE-MEPs) to monitor ISCL removal. We report our retrospective experience with the addition of free-running electromyography (EMG). METHODS: Thirteen patients underwent 14 monitored ISCL excisions. Anesthesia was maintained with minimal inhalant to reduce motoneuron suppression and enhance the myogenic TCE-MEPs. Free-running EMG was examined in the four limbs for evidence of abnormal bursts, prolonged tonic discharge, or sudden electrical silence. Warning of an electromyographic abnormality or myogenic TCE-MEP loss prompted interventions, including blood pressure elevation, a pause in surgery, a wake-up test, or termination of surgery. Pre- and postoperative neurological examinations determined the incidence of new deficits. RESULTS: The combined use of free-running EMG and myogenic TCE-MEPs detected all eight patients with a new motor deficit after surgery; there was one false-positive report. In three of the eight true-positive cases, an electromyographic abnormality immediately anticipated loss of the myogenic TCE-MEPs. Two patients with abnormal EMGs but unchanged myogenic TCE-MEPs experienced mild postoperative worsening of motor deficits; myogenic TCE-MEPs alone would have generated false-negative reports in these cases. CONCLUSION: During resection of ISCLs, free-running EMG can supplement motor tract monitoring by TCE-MEPs. Segmental and suprasegmental elicitation of neurotonic discharges can be observed in four-limb EMG. Abnormal electromyographic bursts, tonic discharge, or abrupt electromyographic silence may anticipate myogenic TCE-MEP loss and predict a postoperative motor deficit.

Intramedullary Cavernous Angiomas of the Spinal Cord in the Pediatric Age Group: A Pediatric Series

The authors have reviewed available data from 7 pediatric patients with intramedullary spinal cord cavernous angioma (ISCCA) reported in the literature, and added from their own series 2 pediatric patients, for a total of 9 patients. This group of pediatric patients’ clinical presentation, course, management and outcome were compared to their adult counterparts as reported in the literature. In contrast to adults, children with symptomatic ISCCA do not show a gender imbalance and the thoracic spinal cord is not predominantly involved. Pediatric patients commonly present with an acute episode and rapid deterioration. A more favorable outcome has been reported in children as compared to adults in the face of relatively similar presenting deficits. As in adults, magnetic resonance imaging (MRI) remains the diagnostic and postoperative test of choice. Complete resection affords the best chance for cure. Symptomatic children with ISCCA characteristically present with an acute deficit and rapid deterioration. MRI of the entire neuraxis is recommended for lesion multiplicity. An attempt at total resection and long-term MRI follow-up are recommended.

Transoral labiomandibular approach to basiocciput chordomas in childhood.

Many excellent reports have dealt with the various aspects of cranial chrodoma. It remains a relatively rare neoplasm, particularly in younger children. The authors have had the opportunity to treat a 5-year-old child harboring a basiocciput chordoma. It extended from the mid-clivus to C3. A transoral labiomandibular approach was used, allowing its resection. No evidence of recurrence was noted 3 years later. A literature search confirmed the rarity of basiocciput chordoma in young children. The perioperative difficulties encountered prompted this report.

Nonteratomatous tumors in the pediatric sacral region.

Study Design. Two institutional experiences in nonteratomatous sacral tumors of the child were analyzed retrospectively. Objectives. To examine noncongenital nonteratomatous sacral tumors, which are more common in older infants and, as a group, are rare. Summary of Background Data. Pediatric sacral tumors usually occur in the newborn period, with most of these tumors being sacrococcygeal teratomas. Other common benign congenital tumors of the sacrum include lipomas, dermoids, and epidermoids. Methods. Six patients were found in a 6-year period. Four patients underwent posterior resection of their tumors. One underwent a combined anterior and posterior approach. One patient underwent a posterior resection and will undergo a second stage anterior approach later to allow for chemotherapy and radiation to shrink the intrapelvic portion of the tumor. Results. Ages ranged from 8 to 11 years. Three were males, and three were females. Five of six presented with back pain, three had constipation, and two had gait difficulties. Pathologies were diverse. They included ganglioneuroma (n = 1), myxopapillary ependymoma (n = 2), primitive neuroectodermal tumor (n = 1), aneurysmal bone cyst (n = 1), and Ewing’s sarcoma (n = 1). No progression of disease has occurred in the follow-up period of 1.5 to 7 years (average, 5 years). Radical resection did not result in instability. Conclusions. In contradistinction to adults, in whom chordomas and metastases are the most common primary and secondary tumors, the pediatric group does not have a predominant pathology. Tumors may attain extremely large sizes and may be very vascular. Multiple therapeutic methods may be required, including adjuvant chemotherapy and, possibly, embolization. Because of the wide range of pathologies, prognosis is varied.

Neuroschisis of the cervical spinal cord in a patient with Klippel-Feil syndrome.

During the neurological work-up of a young patient with Klippel-Feil syndrome, the presence of a neuroschisis of the cervical spinal cord was detected. The patient presented with a transient and acute hemisensory loss and a Horners syndrome of the opposite side. The unusual presentation and radiological findings in a patient with Klippel-Feil syndrome prompted this report.