Patrick T. Tracy

Cauda equina syndrome (CES) from lumbar disc herniations.

Study Design A retrospective review was performed to determine the outcomes of patients with cauda equina syndrome (CES) from a herniated lumbar disc at our institutions. Objective CES from lumbar herniated discs is considered the only absolute indication for surgery. It is considered a neurosurgical emergency with the outcome related to how quickly it is diagnosed and treated. The results of recovery of bladder function are felt by many authors to be related to early diagnosis and surgical intervention. Most authors recommend a wide decompressive laminectomy when surgery is performed. We reviewed our cases to determine if they conformed to these assumptions. Summary of Background Data Although many articles regarding the outcome of CES from herniated lumbar discs suggest that early surgery is superior to surgery that is delayed, others have demonstrated no correlation between time-to-surgery and chances for recovery of neurologic and bladder function. Methods A retrospective review of all patients with lumbar herniated discs and CES from the years 1985 to 2004 was carried out. There were 31 patients, 28 of whom had bladder incontinence or retention requiring catheterization. Six patients were operated within 24 hours, 8 between 24 and 48 hours, and 17 after 48 hours (range: 60 h to 2 wk). Average follow-up was 5 years. Results Twenty-seven of these patients regained continence not requiring catheterization. There was no correlation between the time-to-surgery and recovery of bladder function. There was also no correlation between the time-to-surgery and recovery of motor and sensory function. The majority of patients underwent unilateral hemilaminotomy or bilateral hemilaminotomies; decompressive laminectomy was reserved for patients with underlying spinal stenosis or posteriorly herniated fragments. All of the patients were relieved of their radicular pain. Conclusions In our series of patients with CES and bladder incontinence or retention, over 90% regained continence. Recovery of function was not related to the time to surgical intervention. The majority of the patients were adequately treated without the need for a complete laminectomy.

Magnetic resonance imaging of spinal injury.

Magnetic resonance imaging (MRI) was performed on 30 patients following spinal injury (SI). Spin-echo sequences and surface coils were used for all patients. Plain radiographs, high-resolution computed tomography (CT), and MRI were compared for the delineation of bone, disc, and ligament injury, measurement of sagittal spinal canal diameter and subluxation, epidural hematoma, and spinal cord structure. Myelography or intrathecal contrast-enhanced CT were not performed on any of these patients. Magnetic resonance imaging accurately delineated intraspinal pathology in two of four patients with acute penetrating SI, and was normal in the other two patients. In 16 patients with acute nonpenetrating SI, MRI was superior to CT for visualizing injuries to discs, ligaments, and the spinal cord, while CT was superior to MRI in characterizing bony injury. Computed tomography and MRI provided similar measurements of subluxation in six of six patients and of sagittal spinal canal diameter in three of four patients. In ten patients with chronic SI, MRI demonstrated post-traumatic cysts, myelomalacia, spinal cord edema, and the presence or absence of spinal cord compression. In patients with acute penetrating SI and chronic SI, MRI provided comprehensive clinical information. In patients with acute nonpenetrating SI, the information obtained by MRI complemented the data given by plain radiographs and CT, allowing clinical decisions to be made without the need of invasive Imaging modalities.

Neonatal Cerebral Venous Thrombosis

Five cases of neonatal cerebral venous thrombosis (NCVT) diagnosed by magnetic resonance imaging (MRI) are presented in this report. MRI was specific for the anatomic diagnosis, demonstrating involvement of the superior sagittal sinus in 3 infants or deep venous system in the remaining 2. Four cases were associated with perinatal hypoxia or cranial trauma. Three of these children show significant developmental delays. The increased use of MRI may add significant information on the association of cerebral venous thrombosis with the common systemic illnesses of newborns.

Spinal Dysraphism Use of Magnetic Resonance Imaging in Evaluation

Three cases of children with spinal dysraphism are reported. Magnetic resonance imaging (MRI) was used as a primary diagnostic examination. The ages of the patients were 2 days, 4 years, and 16 years. In all instances the scan gave a precise diagnosis as well as an accurate delineation of the structural abnormalities before surgical treatment. Plain radiographs and ultrasound analysis may not be helpful, and invasive procedures can be associated with morbidity. Technical ease, safety, and anatomic precision suggest that MRI should be performed as a primary radiologic examination in the diagnostic workup of spinal dysraphism.

Recurrence-free chronic subdural hematomas: a retrospective analysis of the instillation of tissue plasminogen activator in addition to twist drill or burr hole drainage in the treatment of chronic subdural hematomas.

OBJECTIVE To evaluate whether increasing the volume drained from chronic subdural hematomas (SDHs) via either twist drill drainage (TDD) or burr hole drainage (BHD) followed by instillation of tissue plasminogen activator (tPA) is more efficacious than simple drainage alone. METHODS Patients admitted over the course of 42 months (2007-2010) to a single institution for treatment of chronic SDH were retrospectively evaluated. RESULTS There were 139 patients treated for chronic SDH; 54 patients were treated with BHD alone, 3 were treated with tPA after BHD, 85 were treated with TDD alone, and 12 were treated with tPA after TDD. Follow-up examinations were performed 1 month after treatment in 13 of 15 patients treated with tPA and 93 of 124 patients treated without tPA. Patients treated with tPA had a significantly lower rate of recurrence than patients treated without tPA (P=0.041). Patients treated with BHD had a recurrence rate of 11.8%, whereas patients treated with BHD and tPA had 0% recurrence. Patients treated with TDD had a recurrence rate of 30%, whereas patients treated with TDD and tPA had 0% recurrence. Without tPA, BHD was found to be a significantly better treatment than TDD (P=0.016). Mean drainage for TDD with tPA was 427.33 mL. There were no complications related to the administration of tPA. CONCLUSIONS This study adds another therapeutic option for patients with chronic SDH requiring treatment. In this retrospective study, the addition of tPA increased the volume of hematoma drained and significantly reduced the incidence of recurrence requiring further intervention regardless of cranial access route. No complications occurred related directly or indirectly to the administration of tPA. Further study of this technique is warranted.

Proton MR Spectroscopy in Patients with Structural MRI‐Negative Temporal Lobe Epilepsy

With conventional magnetic resonance imaging (MRI), 20–30% of patients with temporal lobe epilepsy (TLE) have negative pathological MRI findings. Further investigations of the role of magnetic resonance spectroscopy (MRS) in the pre‐surgical evaluation of patients with MRI‐negative TLE are important to avoid intracranial EEG recording and to better understand the mechanism of the epileptogenic process. This study aimed to compare the measurements of N‐acetylaspartate (NAA), creatine (Cr), and choline (Cho) in the hippocampi of MRI‐negative TLE patients and normal subjects.

Deep brain stimulation for cognitive disorders: insights into targeting nucleus basalis of meynert in Alzheimer dementia.

NOTICE: This is the author’s version of a work that was accepted for publication in World Neurosurgery. Changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may have been made to this work since it was submitted for publication. A definitive version was subsequently published in World Neurosurgery, DOI:10.1016/j.wneu.2013.08.011.

Radiological and pathological findings in three cases of childhood pineocytomas

The radiological and pathological findings in three children with pineocytomas are described. The patients presented with symptoms and signs of increased intracranial pressure. CT scans demonstrated obstructive hydrocephalus, but failed to visualize pineal masses that were subsequently seen on MR scans. A suboccipital, supracerebellar approach was used to obtain tissue for histological diagnosis and, in one case, achieve a total removal. Light microscopy demonstrated typical pineocytomatous rosettes without evidence of gangliocytic or astrocytic differentiation. Electron microscopy revealed numerous dense core vesicles with synaptic ribbons, suggesting neurosecretory capability. These three cases demonstrate the diagnostic advantage of MR imaging for tumors in the pineal region as well as the relatively well-differentiated histopathological characteristics of pineocytomas.

Intracranial hemorrhage following blunt injury to a shunt valve

Case reportThe authors report a case of a child who sustained blunt injury to a shunt valve during a basketball game, which resulted in an intracranial hemorrhage.ConclusionThis occurrence, although rare, reinforces the recommendation for protective headgear when patients with shunts engage in activities that may result in direct impact to the head.