Severe vertebral osteomyelitis in patients with spinal cord injury.

Four patients with spinal cord injury (SCI) experienced severe and unusual clinical manifestations of vertebral osteomyelitis. The main feature of the illness was the development of extensive disease below the level of the SCI. Large paravertebral abscesses pointing to the skin developed in three patients. The fourth patient was seen initially with a persistent draining sinus on a previous nephrectomy incision site before the condition was diagnosed. All four patients underwent surgical debridement of infected bone together with antibiotic therapy. Vertebral osteomyelitis should be considered in patients with SCI and sepsis of uncertain origin.

Osteosarcoma of meninges: clinical, light, and ultrastructural observations of a case.

A primary osteosarcoma of the meninges based on clinical, light, and ultrastructural findings is reported. The neoplasm appears to complete Cushing and Eisenhardt's postulate and expectation of a malignant counterpart of osteoblastic meningioma. The neoplasm lends support to the concept of a primitive multipotential mesenchymal cell in the meninges capable of giving rise to every variety of neoplasms within that potential.

A clinical study of brucellosis in adults in the Asir region of southern Saudi Arabia.

One hundred four Saudi patients with brucellosis who were admitted to Abha General Hospital in the Asir region of southern Saudi Arabia were studied. All the patients had Brucella melitensis infection; 61.5% were females while 38.5% were males. Their mean age was 32 years. Most of the patients (61.5%) lived in the lowland (Tihama) and the majority were shepherds (84.6%). The most common presenting symptoms were fever (100%), sweating (96.2%), headache (76.9%), joint pains (76.9%), and backache (73.1%). Physical findings included fever (96.2%), hepatomegaly (46.2%), splenomegaly (42.3%), tenderness over the spine (30.8%), arthritis (26.9%), and lymphadenopathy (19.2%). Mild anemia, leukopenia, and relative lymphocytosis were common. A history of raw milk ingestion was an important factor in disease transmission (84.6%), followed by close animal contact (73%) and raw liver consumption (63.3%). The study shows the effectiveness of several drug combinations in the treatment of brucellosis and the low relapse rate if the treatment is prolonged for not less than six weeks.

Snake bites in adults from the Asir region of southern Saudi Arabia.

One hundred thirty-two cases of snake bites in adults from the Asir region of southern Saudi Arabia occurring the period 1989-1992 were studied. Of 15 snakes killed, 10 were identified as Echis coloratus and five as were Coluber rhodorachis. The clinical presentation of those bitten by the 10 identified E. coloratus were not very different from cases in which the snake was not identified, favoring the conclusion that the commonest snakes inflicting bites in this region are the saw-scaled or carpet vipers of the genus Echis. The response of adults to bites in this region is generally benign. Patients present mainly with local swelling, pain, redness, and coagulopathy. Minor bleeding was seen in 18.2% of the patients, primarily at the bite site. No serious complications or fatal bleeding occurred. Bites are more common in males during the summer season and mainly in the low land (Tihama). Recommendations regarding management of snake bites of adults from the Asir region are outlined.

High serum calcium in human brucellosis: a case-control study.

In a retrospective case-control study of 58 cases of human brucellosis, adjusted mean serum calcium levels were found to be significantly higher in patients with brucellosis compared with controls: mean (95% confidence interval) = 2.39 (2.35-2.42) mmol/L versus 2.30 (2.26-2.34) mmol/L (P = 0.0012). The possible mechanisms underlying the cause of hypercalcemia in human brucellosis are discussed.

Early clinical response to different therapeutic regimens for human brucellosis.

Seventy-three cases of acute brucellosis were studied in relation to fever duration and hospital stay following different drug combinations, including gentamicin plus cotrimoxazole, rifampicin plus doxycycline, rifampicin plus cotrimoxazole, rifampicin plus tetracycline, streptomycin plus doxycycline, doxycycline plus cotrimoxazole, tetracycline plus cotrimoxazole, and tetracycline plus streptomycin. No statistical significant difference was found between these combinations regarding early clinical response in human brucellosis.

Association of cerebral arteriovenous malformations and spontaneous occlusion of major feeding arteries: clinical and therapeutic implications.

OBJECTIVE: The spontaneous occlusion of a cerebral arteriovenous malformation (AVM) occurs rarely. Occlusion of a parent artery feeding the AVM is even more rare, and its incidence is unknown. We undertook this study to determine the incidence of occlusion of a major artery feeding an AVM and to recommend a management strategy for such an AVM. METHODS: We identified AVMs associated with an occluded artery by performing a retrospective angiographic analysis of 500 patients with AVMs who presented to Henry Ford Hospital from 1976 to 1998. RESULTS: A review of the angiograms revealed that 7 (1.4%) of 500 patients with an AVM had occlusion of one or more major arteries feeding the nidus. In four patients, an internal carotid artery and its bifurcation were occluded; in two patients, the M1 segment of the middle cerebral artery was occluded, and in one patient, a vertebral artery was occluded. Pial collaterals and/or a moyamoya pattern of anastomoses developed in all patients, with the exception of one who had vertebral artery occlusion. Five patients underwent definitive treatment: one received radiosurgery, and four underwent surgical excision. One of the surgically treated patients died of complications from excessive blood loss and coagulopathy, but the other three had no postoperative complications. CONCLUSION: The occlusion of a major artery feeding an AVM occurs rarely (1.4%). These AVMs are moderate to large in size (>3 cm). To prevent collateral flow-related complications of cortical "steal" and hemorrhage, as well as the usual risk of hemorrhage from the AVM itself, surgical management should be considered for these AVMs.

Microsurgical removal of arteriovenous malformations of the basal ganglia.

Arteriovenous malformations in the basal ganglia region have been a problem in neurosurgical practice. We report six cases of deep-seated malformations fed mainly by the perforating branches of the middle cerebral artery. There were no deaths in the series. Four patients returned to their previous activities, and the other two patients had persistent hemiparesis and dysphasia, present preoperatively, with worsening in one case. Both of these patients improved and are independent. We show the feasibility of satisfactory microsurgical treatment of these lesions based on the knowledge of microanatomical studies.

Dural arteriovenous malformations and intracranial hemorrhage.

Intracranial hemorrhage is seen less frequently with dural than with intraparenchymal arteriovenous malformations (AVMs). We report 6 cases of intracranial hemorrhage among our past 10 patients with dural AVMs. A literature search provided 27 other cases of intracranial hemorrhage from a total of 213 reported dural AVMs. Although hemorrhage was relatively infrequent (7.5%) with dural AVMs located primarily within a major venous sinus, bleeding episodes occurred in 20 of the 39 (51%) cases of malformation outside a major sinus. There was primary leptomeningeal venous drainage in all cases with hemorrhage, and a large variceal dilatation was seen in 14 cases (42%). Dural AVMs located outside a major sinus are uncommon, and they have a propensity for serious intracranial hemorrhage.

Atypical and malignant meningiomas: a clinicopathological review.

There has been continuing debate on the subject of malignant meningiomas, but few studies of large series have been reported. We present our experiences with 25 atypical and malignant meningiomas operated on at Henry Ford Hospital between 1976 and 1990. A total of 319 primary intracranial meningiomas were operated on during this period; of these, 294 (92%) were benign, 20 (6.26%) atypical, and 5 (1.7%) malignant. We used a modified histological grading system, based primarily on World Health Organization criteria of malignancy (hypercellularity, loss of architecture, nuclear pleomorphism, mitotic index, tumor necrosis, and brain invasion), to define atypical and malignant meningiomas. Each of these criteria was given a score from 0 to 3, and then partial scores were added to obtain cumulative scores. These total scores were then used to determine what is benign, atypical, and malignant. The peak incidence of atypical and malignant meningiomas was in the seventh and sixth decades, respectively. The predominance of female patients with benign meningiomas was not observed in the nonbenign group. The male:female ratio for atypical and malignant meningiomas was 1:0.9 versus 1:2.3 for benign meningiomas (P = 0.024). The most common presenting symptom and physical sign in our patients was paresis. In reviewing their radiographic features, all patients showed moderate or marked edema on computed tomography. Calcification was exhibited by one patient only and "mushrooming" was seen in three cases. Of the 25 patients, 11 (44%) died during follow-up: 2 in the perioperative period, 8 within the first 5 years, and 1 died 11 years after the diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Spontaneous angiographic obliteration of cerebral arteriovenous malformations.

OBJECTIVE: The factors associated with spontaneous angiographic obliteration of cerebral arteriovenous malformations (AVMs) are not well understood. We present a review of the literature and a report of our experience with six cases (four with no previous treatment intervention and two postoperative residual malformations) that were identified as having occurred during a 20-year period and describe the clinical and lesion features associated with this rare phenomenon. We present the first detailed histological study of a spontaneously thrombosed AVM specimen, including immunohistochemical analysis of angiogenesis factor expression. METHODS: A combined experience in the management of approximately 700 AVMs during 20 years identified six cases of spontaneous angiographic obliteration of cerebral AVMs. A literature review revealed another 24 cases with angiographic documentation of the initial AVMs and follow-up data showing nonfilling of the lesions. Histological analysis of a recently excised lesion included immunostaining with monoclonal antibodies to the antigens of Factor VIII, Tie, vascular endothelial growth factor, and its receptors, Flt-1 and Flk. RESULTS: A single draining vein was a feature in each of our 6 cases and in 12 of 14 (86%) cases from the literature. Hemorrhage as the presenting symptom was identified in 5 of our 6 (83%) cases and in 17 of 24 (71%) of the literature cases. The size of the AVM was less than 6 cm in each of our 6 cases and in 22 of 24 (92%) of the literature cases. A histological examination of a thrombosed AVM surgical specimen revealed persistent patent vascular channels within the lesion. Immunohistochemical analysis with angiogenesis and endothelia-specific factors showed expression of these factors within the lumen of the thrombosed nidus vessels. CONCLUSION: We propose that the occlusion of a single draining vein may lead to total venous outflow obstruction and lesion thrombosis. Hemorrhagic presentation and small nidus may also predispose to this phenomenon. Immunohistochemical analysis of a thrombosed AVM revealed possible ongoing angiogenic changes within the AVM vessels 1 month after angiographically documented thrombosis. It is possible that neovascularization within a thrombosed AVM may lead to lesion recanalization; however, this phenomenon seems to be clinically exceedingly rare.

Spinal epidural abscess: evaluation of factors influencing outcome.

OBJECTIVE: The goal of this study was to critically evaluate the predictive efficacy of various clinical factors in spinal epidural abscess influencing outcome after surgical and/or medical treatment. METHODS: A retrospective analysis of 41 cases of spinal epidural abscess treated at Henry Ford Hospital between 1984 and 1992 was performed. RESULTS: Thirty patients underwent open surgery and received antibiotic therapy, and 11 patients received medical treatment alone. After a mean follow-up period of 20.9 months (range, 4-45 mo), 24 patients (58.5%) had no or minimal deficits, 9 patients (22%) had severe paresis or plegia and/or bowel/bladder dysfunction, and 8 patients (19.5%) died. Univariate analysis revealed patient age, degree of thecal sac compression, spinal location, surgical findings, and septic presentation to be significantly associated with outcome. In multiple logistic regression analysis, increasing age and degree of thecal sac compression were the only factors with significant independent association with poor outcome (P = 0.01 for both). A simple grading system (Grades 0-III) was developed, with patient age, degree of thecal sac compression, and duration of symptoms as the determining criteria. The incidence of poor outcome for patients with Grade 0 was 0%, compared to 85.7% for patients with Grade III. CONCLUSION: We conclude that long-term outcome after treatment of spinal epidural abscess can be predicted with the use of the proposed grading scheme. Surgical drainage plus parenterally administered antibiotics remains the recommended treatment, although medical treatment alone can also be used for certain patients.

Historical perspective on the Department of Neurosurgery at the Henry Ford Hospital.

The Henry Ford Hospital (HFH) was founded in 1915 as a philanthropic gift from Henry Ford, the automobile magnate and inventor of the Model T. The hospital and its organizational structure represented a nonsectarian facility that would provide care for all members of society. The system was patterned after the newest and most modern medical centers at the time in Europe, Canada, and the United States, including the German Krankenhauser, the Johns Hopkins Hospital, the Mayo Clinic, and the Peter Bent Brigham Hospital in Boston. The HFH grew into the Henry Ford Health System in the 1970s to 1990s, with the acquisition of other hospitals, the development of a multiple-region-based clinic system through southeastern Michigan, and the development of comprehensive, vertically integrated health care systems. The Division of Neurosurgery at HFH was established by Albert Crawford in 1926. The tradition of training residents in neurosurgery began in 1946, and the residency training program was accredited by the American Board of Neurosurgery in 1954. In 1970, the Division of Neurosurgery of the Department of Surgery was combined with the Division of Neurology to create the joint Department of Neurology and Neurosurgery. A separate Department of Neurosurgery was established in 1981. Four individuals have served as chairmen of the Department of Neurosurgery at HFH, i.e., Albert Crawford (1926-1952), Robert Knighton (1952-1978), James Ausman (1978-1991), and Mark Rosenblum (1992 to the present). During the 1980s and 1990s, HFH evolved into the vertically integrated, regionally distributed Henry Ford Health System. Under the current direction of Dr. Rosenblum, the Department of Neurosurgery at HFH has grown to include 11 full-time neurosurgeons, 2 neuro-oncologists, and 3 investigators with Ph.D. degrees and has recently expanded into three additional hospitals in southeastern Michigan, paralleling the growth of the system. The faculty annually treats more than 2,000 cases in all neurosurgical subspecialties, ranging from neuro-oncological surgery, cranial base surgery, radiosurgery, cerebrovascular surgery, epilepsy surgery, treatment of movement disorders, pain and spasticity surgery, pediatric neurosurgery, and neurotrauma treatment to complex instrumentation of the spine. This article chronicles the history of the Henry Ford Health System and the Department of Neurosurgery, its research endeavors, and its residency training program.

Language hemispheric dominance in patients with congenital lesions of eloquent brain.

OBJECTIVE: In 90% of normal subjects, the left hemisphere is dominant for language function. We investigated whether congenital lesions of the left perisylvian regions altered cortical language representation in right-handed individuals. METHODS: Using functional magnetic resonance imaging, we studied language hemispheric dominance in five right-handed adult patients with congenitally acquired arteriovenous malformations (AVMs) originating from left hemispheric cortical language regions. The AVMs had not caused neurological symptoms during early development, but patients presented as adults with migraine, seizure, or minor hemorrhage. Results obtained from the AVM patients were contrasted to those from right-handed brain-injured stroke patients recovering from aphasia and to those from right-handed normal subjects. RESULTS: During silent picture naming and verb generation tasks, cortical language networks lateralized primarily to the right hemisphere in the AVM group, compared with the left hemisphere in the normal group. This right hemisphere-shifted language network in the AVM group exceeded the shifts toward right hemispheric dominance found in the stroke group. CONCLUSION: Patients with AVMs affecting the left perisylvian regions recruited the right hemisphere into language processing networks during early development, presumably in response to congenitally aberrant circulation. This early right hemisphere recruitment in the AVM patients exceeded the similar process in the brains of stroke patients whose left cortical language networks were damaged in adulthood. Our data provide evidence of effective plasticity in the developing human brain compared with the mature brain response to injury. Knowledge of cortical language representation should assist presurgical planning in patients with developmental anomalies affecting apparently language-dominant brain regions.

Swan-neck deformity secondary to osteomyelitis of the posterior elements of the cervical spine. Case report.

A case of osteomyelitis is described, involving the posterior elements of the cervical vertebrae in a 7-year-old girl and resulting in swan-neck deformity. Treatment was initiated with antibiotics, and the patient was placed in halo traction. Eventually posterior cervical fusion was performed, which provided excellent stability and correction of the deformity.

Predicting outcome following surgical treatment of unruptured intracranial aneurysms: a proposed grading system.

Surgical treatment of unruptured aneurysms is gaining increased support owing to the recently defined poor long-term natural history of these aneurysms. The benefit of treatment ultimately depends on the relative risk of subsequent aneurysm rupture in untreated patients versus the risk of surgery. To identify those patients at a higher risk from surgery, the authors reviewed the management of 172 patients with unruptured intracranial aneurysms treated at their institution. The size of the aneurysms ranged from 3 to 45 mm (mean 13.7 mm). Twenty-two patients (12.8%) had aneurysms in the posterior circulation, and 32 (18.6%) of these were giant aneurysms. Major morbidity occurred in 12 patients (6.9%) and five patients (2.9%) died. Multivariate logistic analysis of several risk factors revealed that aneurysm size and location had an independent correlation with surgical outcome and that patient age approached statistical significance. Patients presenting with ischemic cerebrovascular disease, in particular, did not have a higher risk of a poor outcome. A simple classification for predicting patients at high risk from surgical morbidity and mortality is proposed. Preoperative grading is based on the size and location of the aneurysm and patient's age. The lowest grade is given to young patients with small anterior circulation aneurysms, and the highest grade includes elderly patients with complex giant posterior circulation aneurysms. A retrospective analysis of this classification demonstrated a strong correlation with postoperative outcome. The incidence of poor outcome progressively increased with a higher grade, ranging from 0% in Grade 0 to 66.6% in Grade VI. An analysis of this classification on 50 consecutive surgically treated patients with unruptured aneurysms not included in the analysis also validated the predictive value of this system. Along with predicting outcome, this classification should provide a standardized format for comparison of results from different clinical centers as well as different therapeutic techniques (surgical vs. endovascular) without omission of significant risk factors found to influence outcome.

Dural arteriovenous malformation of the skull base with intraosseous vascular nidus. Report of two cases.

Intracranial arteriovenous malformations (AVM's) have been classified as pure pial, pure dural, and mixed pial and dural. Dural AVM's are relatively uncommon, with 377 cases documented up to 1990. These lesions were believed to be situated within the walls of the sinuses, but during the last decade researchers discovered a small subgroup of dural AVM's in extrasinusal locations such as the skull base and tentorium. Two of the 17 patients who were studied between 1976 and 1993 had dural AVM's that were entirely intraosseous except for their venous drainage, which was via the dural venous sinuses. Although such intraosseous dural AVM's have not been previously described, the authors elected to group these malformations with dural AVM's because their venous drainage was intracranial and angiograms revealed identical features.

Prolonged external ventricular drainage with percutaneous long-tunnel ventriculostomies.

External ventricular drainage has been used extensively for management of several neurosurgical disorders. The main limitation of this procedure has been the high risk of infection, especially with prolonged drainage. In an effort to minimize the risk of infection, the authors have used a new ventriculostomy technique that involves tunneling the ventricular catheter subcutaneously to an exit site in the lower chest or upper abdomen. This report describes the results of this procedure on 100 consecutive cases. Patients requiring emergency ventriculostomies had short-tunnel ventriculostomies placed at the bedside that were converted to long-tunnel ventriculostomies in the operating room within 5 days. The average duration of drainage was 18.3 days (range 5-40 days). Cerebrospinal fluid was routinely sent for Gram staining and culture to monitor for infection. Prophylactic antibiotic medications were administered only perioperatively. No infection was observed during the first 16 days of drainage in any patient. The overall incidence of infection was 4% and blockage occurred in 6% of the cases. In this series the incidence of ventricular infection was 2.37 per 1000 ventricular drainage days, one of the lowest reported incidences of infection in the literature. This procedure provides a simple and effective method of maintaining long-term ventricular drainage with a very low risk of infection or blockage.

Bilateral superior ophthalmic vein enlargement associated with diffuse cerebral swelling. Report of 11 cases.

Bilateral superior ophthalmic vein (SOV) enlargement has rarely been shown to occur in patients with septic and aseptic cavernous sinus thrombosis, Graves' disease due to obstruction of the SOV by enlarged extraocular muscles, or carotid-cavernous fistulas caused by retrograde flow. The authors describe 11 patients with bilateral SOV enlargement associated with cerebral swelling as detected by computerized tomography scanning. The bilaterally enlarged SOVs returned to a normal size following resolution of cerebral swelling and elevated intracranial pressure. To the authors' knowledge, this is the first report of bilateral SOV enlargement associated with diffuse cerebral swelling that subsequently resolved after treatment of the cerebral edema. The authors believe that the bilateral SOV enlargement was caused by mechanical cavernous sinus venous stagnation due to cerebral swelling, a syndrome that occurs more commonly than currently appreciated.

Cerebral oxygen metabolism during hypothermic circulatory arrest in humans.

Profound hypothermia with circulatory arrest is an important surgical adjuvant that allows protected cessation of cerebral blood flow for a brief period. In seven patients undergoing this procedure, continuous spectroscopic measurement of cerebral hemoglobin oxygen saturation was performed. Circulatory arrest at 18 degrees C was associated with a significant progressive desaturation (p < 0.01) of residual cerebral hemoglobin. Arrest time varied based on operative complexity (range 10 to 65 minutes), and a negative linear correlation between arrest time (y) and oxygen saturation (x) was noted (y = -0.87 x + 64). Five patients whose saturation remained above 35% had no neurological injury attributable to hypoxia. One patient (Hunt and Hess Grade 0) whose saturation fell below 35% had evidence of a global hypoxic injury at postmortem examination. Spectroscopically measured cerebral hemoglobin saturation (cerebral oximetry) may be used to monitor metabolic activity during circulatory arrest. Although the clinical utility of such monitoring cannot be established at this time, the potential may exist to prolong the safe duration of induced circulatory arrest for cerebral protection.