Mark R. McLaughlin

Traumatic basilar aneurysm after endoscopic third ventriculostomy: case report.

OBJECTIVE AND IMPORTANCE: This case illustrates that although endoscopic third ventriculostomy for patients with aqueductal stenosis is successful and minimally invasive, it can have severe, life-threatening complications. CLINICAL PRESENTATION: A 3-year-old girl presented with hydrocephalus and aqueductal stenosis. She underwent endoscopic third ventriculostomy with laser fenestration of the third ventricular floor. During the procedure, she developed a severe intraventricular hemorrhage that required prolonged external ventricular drainage and ultimately ventriculoperitoneal shunting. Despite having a negative angiogram after the procedure, she presented 1 month later with a subarachnoid hemorrhage and a traumatic basilar tip aneurysm. INTERVENTION: The patient underwent a right subtemporal approach with clip ligation of the aneurysm and subsequently had a good recovery. CONCLUSION: Hemorrhagic complications after endoscopic third ventriculostomy are rare. The formation of a traumatic basilar tip aneurysm after this procedure has not been reported in the literature. Laser fenestration of the third ventricular floor may increase the risk of this event.

The prospective natural history of cerebral venous malformations.

OBJECTIVE A 10-year prospective clinical and magnetic resonance imaging study was undertaken to determine the natural history of venous malformations. We assessed the hemorrhage rate and morbidity associated with venous malformations of the brain. PATIENTS AND METHODS From 1986 to 1996, 80 patients with venous malformations were referred to the University of Pittsburgh multidisciplinary vascular malformation study group for evaluation. Observation was recommended for all patients. Follow-up clinical information was obtained from patients or their referring physicians through questionnaire or phone conversation. RESULTS Twenty-two patients presented with neurological signs or symptoms that were thought to be related to the malformations (nine with headaches, four with seizures, three with sensory symptoms, three with motor deficits, two with trigeminal neuralgia, and one with an extrapyramidal disorder). Twenty-three patients presented with headaches that were not considered to be related to the malformations. The retrospective hemorrhage rate (from birth to study entry) was 0.61% (18 bleeds in 2,949 patient-years). Sixteen patients had sustained previous brain hemorrhage in the region of the venous malformations, two of whom had suffered subsequent hemorrhage. During the prospective follow-up period totaling 298 patient-years of clinical observation, two patients suffered hemorrhage (0.68% per year), but only one had a symptomatic bleed (0.34% per year). This patient had not hemorrhaged previously. One of these patients remained asymptomatic, whereas the second developed temporary worsening of facial paresthesias. No patient died as a result of the venous malformations. CONCLUSION The hemorrhage rate of a patient with venous malformations is similar to the rates presented in previous reports for patients with cavernous malformations without previous symptomatic hemorrhage. We think that hemorrhage in a patient with venous malformations may be related to an underlying but not yet documented cavernous malformation. Because of the low risk for new neurological events, we advocate conservative management. The risks associated with surgical intervention greatly exceed the low risk of morbidity related to venous malformation hemorrhage.

Cost Advantages of Two-Level Anterior Cervical Fusion with Rigid Internal Fixation for Radiculopathy and Degenerative Disease

BACKGROUND Conventional anterior cervical discectomy with fusion is thought to require postoperative neck immobilization for the promotion of bony fusion. Rigid internal fixation with anterior cervical plates may decrease graft-related complications and provide immediate stability. This stability may obviate postoperative external immobilization. METHODS This report reviews one surgeons experience with the use of rigid internal fixation for two-level anterior cervical discectomy and fusion for radiculopathy to promote early mobilization without external bracing. It compares outcomes and costs with a similar population of patients treated with anterior cervical discectomy and fusion who did not undergo rigid internal fixation. We compared patients who underwent two-level allograft anterior cervical discectomy and fusion with or without rigid internal fixation between 1989 and 1994 performed by a single surgeon (FJP) to evaluate the cost advantages and outcome of each procedure. All patients had clinical evidence of cervical radiculopathy unresponsive to medical therapy with magnetic resonance imaging confirmation of the appropriate nerve root impingement. Thirty-nine patients underwent two-level Cloward allograft fusion using Synthes anterior cervical locking plates, 25 underwent identical fusion without plating. Follow-up was 6 months to 4 years (mean, 31 months). RESULTS Twenty-three of 25 patients in the nonplated group and 36 of 39 patients in the plated group achieved excellent or good outcomes using the Odom criteria. There were six complications (two major and four minor) in each group. Patients who underwent plating returned to light activities (mean, 17 vs. 29 days), driving (28 vs. 57 days), and unrestricted work (66 vs. 136 days) sooner than non-plated patients (p < 0.05, paired t test). No patient with plates was given external immobilization. CONCLUSIONS Two-level anterior cervical discectomy and fusion with anterior plating for radiculopathy is safe, effective, and seems to provide shorter convalescence compared with conventional anterior cervical discectomy and fusion. Patients returned to unrestricted work sooner, thus reducing short-term disability. Rigid internal fixation may provide cost advantages to patients and insurance disability providers. The authors conclude that the increased cost of treatment for rigid internal fixation is more than offset by the benefits of earlier mobilization.

Beneficial effects of the radioprotectant 21-aminosteroid U-74389G in a radiosurgery rat malignant glioma model

Abstract Purpose: To evaluate the radioprotectant effects of the 21-aminosteroid U-74389G on the rat C6 glioma model after stereotactic radiosurgery. Because radiosurgery causes both tumor cytotoxicity, as well as regional brain edema, we hypothesized that this drug might exhibit advantageous or deleterious effects on healthy and neoplastic tissue. Methods: Rats were implanted with 10 6 C6 glioma cells into the right frontal brain and randomized to a Control Group ( n = 18), radiosurgery on Day 14 (50% isodose=35 Gy) ( n = 15), or radiosurgery preceded by a single 15 mg/kg intravenous dose of 21-aminosteroid ( n = 27). All animals were killed by 90 days and evaluated for survival, tumor size, the presence or absence of regional parenchymal edema, or radiation-induced vasculopathy. Results: After tumor implantation, median survival in the Control Group was 23 days. Significant improvements in median survival were noted after RS alone (median, 31 days; p = 0.02), and RS plus 21-aminosteroid (median, 59 days; p p = 0.002), and after RS plus 21-aminosteroid, 2.9 mm ( p = 0.0002). In the Control Group, the tumor grew as a hypercellular, compact mass. Only 3 of 18 animals had peritumoral edema. In contrast, 7 of 15 animals in the RS group had evidence of edema ( p = 0.006), but rats that received 21-aminosteroid showed no increase compared to controls ( p = 0.38). Similarly, 6 of 15 animals that had radiosurgery alone showed evidence of vasculopathy ( p = 0.005) compared to no animals in the control group and only 2 of 27 aminosteroid-treated animals. Conclusions: The 21-aminosteroid U-74389G exhibits a radioprotectant effect on normal brain tissue, but does not appear to protect the tumor in an in vivo rat radiosurgery model. We believe that the observed beneficial effects on healthy brain led to significant prolongation of animal survival; perhaps, by limiting the adverse effects of high-dose radiosurgery. This radioprotectant should now be evaluated in randomized clinical trials in patients with malignant brain tumors.

Acute subdural hematoma caused by a ruptured giant intracavernous aneurysm: case report.

A case of a giant intracavernous carotid artery aneurysm that presented as an acute subdural hematoma is reported. The patient was initially treated unsuccessfully with endovascular aneurysmal embolization and subsequently underwent attempted microsurgical clipping with preservation of the parent artery. At operation, an angiogram showed occlusion of the parent vessel, and the aneurysm was trapped by occlusion of the internal carotid artery. The patient did well for 2 days postoperatively but then developed contralateral progressive hemiplegia and aphasia. Emergent subsequent exploration and middle cerebral artery embolectomy were performed, and the hemiplegia and aphasia resolved rapidly. At 2-year follow-up, the patient continues to do well. To our knowledge, this is the first reported case of a patient who survived an acute subdural hematoma caused by an intracavernous carotid artery aneurysm.

MANAGEMENT OF LOW BACK PAIN

BACKGROUND Low back pain is both a common and pervasive problem in society today. The physical pain itself represents only a small fraction of the overall disability. On an individual level, the emotional cost of dealing with chronic pain and the loss of independence can be devastating. On a societal level, the loss of workforce productivity and the need for additional expenditure of diminished health care resources may be staggering. REVIEW SUMMARY The syndrome of low back pain is reviewed with descriptions of the common symptoms, clinical signs, and pathologic basis of the disease process. The diagnostic value of the clinical examination and various neuroimaging modalities is discussed. Generation of differential diagnoses on the basis of available clinical information is emphasized. Treatment options, including nonoperative and surgical interventions, are evaluated for relative merit and efficacy. CONCLUSIONS Low back pain is a common problem with widespread implications. Management is based on understanding the causative lesion and judicious application of proven therapies. (THE NEUROLOGIST 6:326‐337, 2000)

Discogenic Lumbar Disease

The treatment of discogenic lumbar disease is a major challenge faced by physicians throughout the world. This condition affects many patients and will inevitably become more prevalent with a rapidly aging population. Disc degeneration tends to increase rapidly with age so that 10% of 50-year-old and 60% of 70-year-old discs are severely degenerated [1]. The current special issue explores several crucial angles related to the pathology, diagnosis, and treatment of discogenic lumbar disease.

Current Techniques in Image-Guided Spine Surgery

Learning Objectives: After reading this article, the participant should be able to:1. Describe the presently available spinal image guided stereotactic methods.2. Recall the computer assisted image guided spinal technique including indications, methodology and limitations.3. Recall the potential use of virtual floroscopy for spinal stereotaxis including its indications, methodology and limitations.

Beneficial Effects of the Radio protectant 21-Aminosteroid U-74389G in a Radiosurgery Rat Malignant Glioma Model

PURPOSE To evaluate the radioprotectant effects of the 21-aminosteroid U-74389G on the rat C6 glioma model after stereotactic radiosurgery. Because radiosurgery causes both tumor cytotoxicity, as well as regional brain edema, we hypothesized that this drug might exhibit advantageous or deleterious effects on healthy and neoplastic tissue. METHODS Rats were implanted with 10(6) C6 glioma cells into the right frontal brain and randomized to a Control Group (n = 18), radiosurgery on Day 14 (50% isodose = 35 Gy) (n = 15), or radiosurgery preceded by a single 15 mg/kg intravenous dose of 21-aminosteroid (n = 27). All animals were killed by 90 days and evaluated for survival, tumor size, the presence or absence of regional parenchymal edema, or radiation-induced vasculopathy. RESULTS After tumor implantation, median survival in the Control Group was 23 days. Significant improvements in median survival were noted after RS alone (median, 31 days; p = 0.02), and RS plus 21-aminosteroid (median, 59 days; p < 0.0001). In the Control Group, mean tumor diameter was 5.4 mm. After RS alone, the mean diameter was 3.2 mm (p = 0.002), and after RS plus 21-aminosteroid, 2.9 mm (p = 0.0002). In the Control Group, the tumor grew as a hypercellular, compact mass. Only 3 of 18 animals had peritumoral edema. In contrast, 7 of 15 animals in the RS group had evidence of edema (p = 0.006), but rats that received 21-aminosteroid showed no increase compared to controls (p = 0.38). Similarly, 6 of 15 animals that had radiosurgery alone showed evidence of vasculopathy (p = 0.005) compared to no animals in the control group and only 2 of 27 aminosteroid-treated animals. CONCLUSIONS The 21-aminosteroid U-74389G exhibits a radioprotectant effect on normal brain tissue, but does not appear to protect the tumor in an in vivo rat radiosurgery model. We believe that the observed beneficial effects on healthy brain led to significant prolongation of animal survival; perhaps, by limiting the adverse effects of high-dose radiosurgery. This radioprotectant should now be evaluated in randomized clinical trials in patients with malignant brain tumors.