Stephen R. Freidberg

Experience with Symptomatic Spinal Epidural Cysts

Epidural cysts, either synovial or ganglion, are an unusual cause of epidural compressive syndromes. We report a series of 26 patients with cysts, including 1 cervical, 2 thoracic, and 23 lumbar. Complaints at the time of admission and findings were similar to those associated with other epidural lesions at the same locations. The surgical technique is similar to that for other spinal lesions, with a wide exposure to enable a clear view of the cyst and surrounding structures, and is governed by imaging studies. Patients with cervical and thoracic lumbar cysts were free of symptoms and signs postoperatively. Of the 23 patients with lumbar cysts, 15 were free of symptoms after an operation, 7 had symptomatic improvement but had some pain and neurological findings, and 1 patient had no improvement. Computed tomography and magnetic resonance imaging permit accurate preoperative evaluation.

Characterization of Chemical Meningitis after Neurological Surgery

We reviewed the records of 70 consecutive adult patients with meningitis after a neurosurgical procedure, to determine the characteristics that might help to distinguish a sterile postoperative chemical meningitis from bacterial infection. The spinal fluid profiles in bacterial and chemical meningitis are similar. The exceptions are that a spinal fluid white blood cell count > 7500/microL (7500 x 10(6)/L) and a glucose level of < 10 mg/dL were not found in any case of chemical meningitis. The clinical setting and clinical manifestations were distinct enough that no antibiotic was administered after lumbar puncture to 30 (43%) of the 70 patients with postoperative meningitis. Chemical meningitis was infrequent after surgery involving the spine and sinuses. Patients with chemical meningitis did not have purulent wound drainage or significant wound erythema or tenderness, coma, new focal neurological findings, or onset of a new seizure disorder. They rarely had temperatures > 39.4 degrees C or cerebrospinal fluid rhinorrhea or otorrhea.

Repair of injured vertebral artery in anterior cervical procedures

Study Design A case report of treatment of injury to the vertebral artery in anterior cervical procedures is presented with a review of the literature. Objectives The feasibility of direct surgical repair is suggested. Summary of Background Data Currently, ligation or tamponade is accepted as the treatment of injury to the vertebral artery in anterior cervical surgery. Significant morbidity can result from this method. Direct repair should eliminate this morbidity. Methods A report is presented of a patient who sustained injury to the vertebral artery, and the technique of repair is discussed. The literature was reviewed. Results The outcome was successful regarding both repair and the primary procedure. Conclusions Although it is impossible to make a recommendation based on a single incident, this technique is believed to minimize postoperative sequelae that can be associated with occlusion of the vertebral artery.

MRI appearances of an ectopic pituitary adenoma: case report and review of the literature

MR images of an ectopic pituitary adenoma have been published in only a single case, a suprasellar mass. We present a patient with Cushings disease in whom MRI revealed a pituitary adenoma within the sphenoid sinus. Radiologic characteristics of ectopic pituitary adenomas are reviewed, with emphasis on MRI, which demonstrates a soft tissue mass, isointense with gray matter on T1-weighted images, which enhances in a heterogeneous manner.

Brain necrosis after radiotherapy for primary intracerebral tumor.

Radiotherapy is a standard postoperative treatment for cerebral glioma. We have observed the onset of symptoms related to brain necrosis, as opposed to recurrent tumor, in surviving patients. This has been manifest as dementia with a computed tomographic pattern of low density in the frontal lobe uninvolved with tumor, but within the field of radiotherapy. Two patients presented with mass lesions also unrelated to recurrent tumor. We question the necessity of full brain irradiation and suggest that radiotherapy techniques be altered to target the tumor and not encompass the entire brain.

Closure of Cerebrospinal Fluid Leakage after Transsphenoidal Surgery

ABSTRACTIT IS NECESSARY to pack the sella turcica to prevent the leakage of cerebrospinal fluid after transsphenoidal surgery if the arachnoid has been torn. The packing is usually supported by nasal cartilage. If this is not available, we recommend the Synthes minifragment plate to support the intr

Ataxic Creutzfeldt-Jakob disease: diagnostic techniques and neuropathologic observations in early disease.

We studied two cases of ataxic Creutzfeldt-Jakob disease. EEG, CT, evoked responses, and CSF were normal in one purely ataxic patient. Diagnosis was established by cerebellar biopsy. Autopsy demonstrated devastating spongiform changes in the cerebellum, basal ganglia, and thalamus with rare focal changes in cerebral cortex. In the second patient, late generalized changes developed with dementia. Diagnostic studies included abnormal visual evoked responses, CSF with abnormal oligoclonal bands and IgG, and subacute spongiform encephalopathy in frontal lobe biopsy. Early diagnosis is best established by biopsy of brain areas most likely to be involved on the basis of clinical neurologic findings.

The Consequence of Delayed Neurosurgical Care at Tikur Anbessa Hospital, Addis Ababa, Ethiopia

Tikur Anbessa Hospital (TAH) is the major teaching hospital for Addis Ababa University and the only tertiary referral hospital for neurosurgery in Ethiopia. We explore the consequence of delayed treatment by examining the current system in place for treating patients and the wait times experienced by patients. A retrospective chart review was carried out on patients who received a neurosurgical operation at TAH between January 1 and June 30, 2007. We divided patients into those requiring an elective procedure and those requiring emergency surgical care. Based on data entered in the chart, we determined the length of time from symptom onset to neurosurgical consultation and the time from consultation to receiving an operation. Selective cases were chosen to illustrate the effects of delayed care. A total of 172 neurosurgical operations were performed between January 1 and June 30, 2007, at TAH. Of these, 107 (62.2%) charts were available for retrospective review. Fifty-six elective cases were reviewed. The median time from symptom onset to neurosurgical consultation was 185 days. The median time from neurosurgical consultation to operation was 44 days. Fifty-one trauma/emergency surgical cases were reviewed. The median time from symptom onset or traumatic event to neurosurgical consultation was 3 days. The median time from neurosurgical consultation to operation was 1 day. Delayed neurosurgical care comes with a high personal and social cost. By measuring the time from diagnosis to treatment and taking note of institutional practices, changes can be initiated to improve patient waiting times.

Glucocorticoid Dependency as A Prognostic Factor in Radiotherapy for Cerebral Gliomas

Records of 76 consecutive patients treated with radiotherapy for cerebral gliomas were reviewed. Eleven patients had no tissue diagnosis, and their outcome was comparable to that of patients with glioblastoma. Patients with other histologic diagnoses had much better results. Among the entire study population, the most important prognostic factors included age and histologic grade. Even with stratification by histologic grade and age, glucocorticoid (steroid) dependency was a reliable prognostic indicator in terms of survival. Fifteen of the 47 patients (32%) who were less steroid dependant are still alive with a median survival time of 29 months. Among the 29 patients who were heavily dependant on steroids during the course of radiotherapy, the median survival time was 5 months with only 2 patients (7%) still alive.

Modification of the Gouda frame to allow stereotactic biopsy of the brain using the GE 8800 computed tomographic scanner.

The Gouda stereotactic frame has been modified to interface with the GE 8800 scanner. The patient, attached to the frame, is scanned and then moved to the operating room for a stereotactic biopsy. This is a safe, accurate method of obtaining biopsy specimens of otherwise inaccessible tumors of the brain.