Image-guided keyhole evacuation of spontaneous supratentorial intracerebral hemorrhage.

INTRODUCTION: Treatment of spontaneous supratentorial intracerebral hemorrhage (SICH) is controversial. This study aims to evaluate the outcome and invasiveness of one surgical approach that provides complete evacuation of SICH, the image-guided keyhole evacuation. METHODS: The technique was employed in 20 consecutive patients, nine of whom harbored deep hematomas. The hematoma was evacuated through a keyhole minicraniotomy, 2.5 cm in diameter. Computerised tomographic (CT) scan was performed at the end of the procedure to confirm completeness of evacuation. Invasiveness was assessed by comparing initial neurological status determined by Glasgow Coma Scale (GCS) scores and National Institutes of Health Stroke Scale (NIHSS) scores with the third and seventh postoperative day scores, and by radiological findings. Outcome at six months was assessed by the Extended Glasgow Outcome Scale, and by comparing the initial and 6 month modified Rankin Scale scores. RESULTS: Mean age was 63.7+/-14.8 years, mean volume was 41.6+/-17.5 mL, and mean time to surgery was 17.6+/-13.2 h. CT scans at the end of the procedure showed complete evacuation (mean 97.5%), and 60% decrease of both mean midline shift and mean edema volume (p=0.005). Neurological assessment at the end of the first postoperative week showed significant improvement (p<0.0001). At six months, 90% of the patients had achieved recovery to independence, and one patient had died. CONCLUSION: The image-guided keyhole approach allowed prompt evacuation of SICH and resulted in a high rate of functional recovery and low mortality. This is a minimally invasive technique that is highly effective in immediate and complete hematoma evacuation.

Comparison of unilateral pallidotomy and subthalamotomy findings in advanced idiopathic Parkinson's disease.

A prospective, randomized, double-blind pilot study to compare the results of stereotactic unilateral pallidotomy and subthalamotomy in advanced idiopathic Parkinson's disease (PD) refractory to medical treatment was designed. Ten consecutive patients (mean age, 58.4 +/- 6.8 years; 7 men, 3 women) with similar characteristics at the duration of disease (mean disease time, 8.4 +/- 3.5 years), disabling motor fluctuations (Hoehn & Yahr stage 3-5 in off-drug phases) and levodopa-induced dyskinesias were selected. All patients had bilateral symptoms and their levodopa equivalent dosing were analysed. Six patients were operated on in the globus pallidus interna (GPi) and four in the subthalamic nucleus (STN). Clinical evaluation included the use of the Unified Parkinson's Disease Rating Scale (UPDRS), Hoehn&Yahr score and Schwab England activities of daily living (ADL) score in 'on'- and 'off'-drug conditions before surgery and 6 months after surgery. There was statistically significant improvement in all contralateral major parkinsonian motor signs in all patients followed for 6 months. Levodopa equivalent daily intake was significantly reduced in the STN group. Changes in UPDRS, Hoehn & Yahr and Schwab England ADL scores were similar in both groups. Cognitive functions were unchanged in both groups. Complications were observed in two patients: one had a left homonymous hemianopsia after pallidotomy and another one developed left hemiballistic movements 3 days after subthalamotomy which partly improved within 1 month with Valproate 1000 mg/day. The findings of this study suggest that lesions of the unilateral STN and GPi are equally effective treatment for patients with advanced PD refractory to medical treatment.

The endoscopic endonasal trans-sphenoidal approach to the sellar and suprasellar area. Anatomic study.

AIM: The microscopic trans-sphenoidal approach has been the treatment of choice of different sellar lesions over the last thirty years. However, due to several advantages brought by the endoscope, which provides a panoramic and close up view of all the anatomic landmarks either in the sphenoid sinus and in the sellar region, an increasing interest for the trans-sphenoidal approach to the sellar and suprasellar region is being noticed in the recent past years. Since the endoscopic approach drives the surgeon through a corridor whose walls were previously hidden by the nasal speculum, the precise knowledge of the endoscopic anatomy and the anatomical landmarks of the surgical approach are essential to better explore the mentioned advantages. METHODS: The endoscopic endonasal approach to the sellar region was performed in 40 adult fresh cadavers, with the aim of describing the anatomical landmarks for a safe realization of the surgical approach. RESULTS: The anatomic features and the variations of the sphenoid ostia, sphenoid sinus and septae, sella turcica, optic and carotid protuberances and their relationships have been described, as well as supra and parasellar neurovascular structures. CONCLUSION: The endoscopic endonasal trans-sphenoidal approach provides a straight approach to the sellar region, where it offers a multiangled and close-up view of all the relevant neurovascular structures.

Primary dural melanomas: report of two cases and review of the literature.

Two cases of primary melanoma of the central nervous system originating from the dura mater and without involvement of the leptomeninges are described. In one case, the tumor was located extradurally with firm attachment to the dura mater and dural melanosis. In the other case, the dura was involved diffusely with multiple discrete masses of 1 to 3 mm in diameter. A literature review revealed five other cases of primary dural melanoma. A discussion of the origin of primary dural melanoma is presented.

Adult aqueductal stenosis presenting with fluctuating hearing loss and vertigo. Report of two cases.

Two cases of aqueductal stenosis presenting with fluctuating hearing loss, tinnitus, and vertigo are presented. Audiovestibulometric assessment of both cases disclosed the characteristic pattern of disorder of the membranous inner ear. Non-tumoral aqueductal stenosis was demonstrated by computerized tomography in one case and by positive contrast ventriculography in the other. Shunting procedures of the cerebrospinal fluid resulted in resolution of inner ear dysfunction in both patients.

Alveolar hydatid disease of the brain. Report of four cases.

Four cases of alveolar hydatid disease of the brain encountered within 27 months in eastern Turkey are reported. All of the patients were male farmers who presented with signs of cerebral tumor. Two of the patients were shown to harbor hepatic lesions and one of them had pulmonary metastases. The cerebral lesions were removed in toto and neurological recovery was obtained in all four patients. A review of the literature revealed only five previously reported cases treated surgically. It is concluded that cerebral Echinococcus multilocularis lesions are amenable to surgery, and that their removal provides useful prolongation of life despite the presence of hepatic or pulmonary disease.

Successful therapy combined with surgery for severe post-transplant nocardiosis.

We report a case of a 35-year-old man with nocardiosis infection involving soft tissue and the central nervous system who had received a cadaveric donor kidney. The patient was admitted with fever, malaise and right shoulder pain. Soft tissue abscess was seen on ultrasound examination. It was presumed due to gram (+) microorganisms, so 4 g day (IV) ampicillin/sulbactam was started empirically once the abscess was drained. Nocardia asteroides was found in the pus specimen. On the second day in hospital, severe headache, ataxia and signs of meningeal irritation appeared. The cranial CT showed two intracranial abscesses in the frontal lobe and cerebellum. We assumed Nocardia asteroides was the infective agent for the cerebral abscesses, so antibiotic therapy was switched to trimethoprim-sulphamethox-asole (3x160/800 mg/d). Nausea and vomiting occurred on the fifth day of therapy, improving after drainage from the frontal abscess. However, these complaints recurred five days later. CT showed cerebellar abscess had become bigger. The patient's complaints improved after the second surgical drainage. N. asteroides was again grown in the aspiration fluids of both cerebral abscesses. Complete regression of the abscesses was seen in the CT after two months. Co-trimoxazole was continued for six months then withdrawn. Graft dysfunction was not observed. Early medical and surgical interventions may be life-saving in this potentially lethal disease.

Supratentorial intracerebral schwannomas.

A case of frontotemporal intracerebral schwannoma in a 16-year-old girl with epilepsy and progressive hemiparesis of 3 years' duration is described. The histologic diagnosis and possible sites of origin are discussed. In addition, five previously reported cases of supratentorial intracerebral schwannoma are discussed. All of the patients reviewed presented with epilepsy early in life, and there was no association with neurofibromatosis.

Tethered cord in the adult mimicking the lumbar disc syndrome: report of two cases.

Two adult patients with tethered cords whose symptoms mimicked those of lumbosacral intervertebral disc herniation are reported. Neither one of the patients had cutaneous stigmata, and one had normal plain x-ray examination of the spine. Magnetic resonance imaging in both patients demonstrated tethering of the cord. Untethering of the cord resulted in disappearance of the symptoms in both patients. These unusual cases suggest that tethering of the cord must be included in the differential diagnosis of the herniated lumbar intervertebral disc syndrome.

Urgent total removal of a lower clival meningioma.

A 50-year-old woman was first examined in the emergency room because of inadequate ventilation, rapidly developing respiratory paralysis, and papilledema. Multiple cranial nerve palsies and tetraparesis were present. Carotid angiogram demonstrated bilateral ventricular dilatation. Facilities for computerized tomography and vertebral angiography were not available. Ventriculograms revealed a filling defect of the fourth ventricle without displacement of the midline structures. Immediate exploration of the posterior fossa through a suboccipital craniectomy permitted microsurgical excision of a meningioma of the lower clivus. Spontaneous respirations returned postoperatively and a complete return of neurological functions ensued. The pertinent literature is reviewed.

Bromocriptine-induced cerebrospinal fluid fistula in patients with macroprolactinomas: report of three cases and a review of the literature.

Bromocriptine therapy for macroprolactinoma induced cerebrospinal fluid (CSF) rhinorrhea in three patients. The tumor had extended well beyond the sella turcica and caused bony erosion in all the cases. All three patients responded to bromocriptine therapy rapidly. CSF fistula occurred concomitantly with the reduction of tumor size and caused meningitis in two of the patients. Withdrawal of bromocriptine resulted in cessation of the leakage. One of the patients underwent transsphenoidal repair. Two patients refused surgery. This potentially lethal complication encountered in these three cases demonstrates the need for close supervision of macroprolactinoma patients with skull base erosion placed under bromocriptine therapy.

Stereotactic surgery in the management of brain abscess.

BACKGROUND: Bacterial brain abscesses can be diagnosed and treated with stereotactic aspiration. METHODS: From 1991 to 1997 we have used computed tomography-guided stereotactic aspiration to diagnose and treat 21 patients with a total of 58 bacterial brain abscesses. The ages of the patients ranged from 4 to 72 years (median 25 years); 11 of these 21 patients had multiple abscesses. The number of abscesses per patient with multiple abscesses ranged from 2 to 9, all located deep in subcortical white matter. RESULTS: All patients underwent stereotactic surgical drainage and an 8-week intravenous antibiotic medical treatment. Of the 58 abscesses, 23 were aspirated. Of these 23 abscesses, 19 were radiologically stage III or IV and four were stage I or II. Pathological examination confirmed radiological staging in 19 patients (83%). Except for the three patients who have mild residual hemiparesis and one patient recovering from ataxia, all patients had complete neurological recovery. CONCLUSIONS: Computed tomography-guided stereotaxy achieved all the objectives of management; namely, ascertaining the diagnosis, draining the content of the mass, and obtaining pus for accurate bacteriological diagnosis without morbidity. Stereotactic aspiration combined with an 8-week intravenous antibiotic regimen has yielded an effective therapeutic result in all of our abscesses, small or large, solitary or multiple, superficial or deep-seated. A high radiological-pathological correlation was also deduced from this study.

Formalin fixing and paraffin embedding may lead to extra band development in PCR.

The molecular biological analysis of infectious agents requires the availability of a reliable source of microorganisms to be used to recover DNA. Clinical samples can be obtained directly from infected patients or can be propagated using in vitro or in vivo systems. However, repeated sampling from patients is not always possible as the procedure may be invasive or unpleasant, or it is not possible to catch the same agent at the time of second sampling. Moreover, the techniques used may also produce false-positive and false-negative results. We therefore studied the impact of formalin-fixing and paraffin embedding on tissue sampling, and the methodologies such as DNA isolation and PCR amplification of DNAs from archival materials in the diagnosis of Mycobacterium tuberculosis. PCR analyses were done according to standard methods with some modifications. Demonstration of mycobacteria was successful both in tissue sections of the formalin-fixed lymph nodes and in stained fresh materials from patients. However, the results showed the presence of two extra bands in the gel. We accounted for extra band development due to the harshness of the methodology used to isolate nucleic acids from formalin-fixed and paraffin embedded tissue samples or the nature of the fixation procedure, or because of the time passed during storage in which alteration in the chromosomal DNA would take place. Thus, if disease- and tissue specific morphological features, such as sample size, type of fixation, and intralesional heterogeneity are ignored, errors because of sampling and methodologies used may lead to false-positive and false-negative results.

Stereotactically guided microsurgical removal of colloid cysts.

BACKGROUND: The surgical technique and clinical results for a series of 16 consecutive patients who underwent resection of third ventricular colloid cysts through a stereotactically guided cylindrical retractor are presented. METHODS: Between March 1993 and December 2002, 16 patients, 11 males and 5 females with a mean age of 36, were admitted with colloid cysts of the third ventricle. Four patients had undergone previous surgery, of which two were simple aspirations, one endoscopic aspiration, and one transcallosal partial removal. Four patients required emergency ventriculostomies on admission. In all patients the foramen of Monro was targeted using a Leksell stereotactic frame. A coronal craniotomy three to four cm in diameter was performed and a cylindrical retractor 14 mm in diameter was advanced to the target. Microsurgical removal of the cyst was then performed through the retractor. FINDINGS: Total removal of the cyst was achieved in all cases. Median follow-up time is 42 months. Complete resolution of symptoms occured in all patients. Control magnetic resonance imaging revealed no residual cysts. All patients have returned to their previous occupations without sequelae or epilepsy. CONCLUSION: The outcome obtained in this series has shown that transfrontal transforaminal total removal of colloid cysts through a stereotactically guided cylindrical retractor is a safe procedure.

Interstitial irradiation for craniopharyngioma.

The results of interstitial irradiation treatment for craniopharyngioma in two patients with six year follow-ups are presented. Stereotactic interstitial irradiation with Iodine-125 sources as sole therapy was employed in two adult patients who refused surgical resection. The diagnoses were confirmed by stereotactic biopsy. The first tumour which underwent interstitial irradiation was solid and 4 cm in diameter, and the second, 2.7 cm in diameter, had both cystic and solid components. The implanted Iodine-125 seeds delivered 67 Gy and 60 Gy to tumour periphery at the rate of 12 and 14 cGy/h, respectively, were removed at the end of designated radiation periods. Tumour shrinkage and central hypodensity, first observed 3 months after irradiation, continued until one tumour shrank to less than 1 cm at 12 months, and the other disappeared completely at 24 months. In both cases functional integrity was restored, and neither radiation induced toxicity nor recurrence has occurred six years after treatment. The results in these two cases suggest that solid craniopharyngiomas are sensitive to interstitial irradiation.

Non-resective management of pineoblastoma.

The results of a non-resective treatment approach for pineoblastoma comprising stereotactic biopsy, cerebrospinal fluid diversion, and fractionated radiotherapy in six patients over a period of six years are presented. There were three male and three female patients, with a median age at diagnosis of 20 years. Magnetic resonance imaging of the spine, ventricular cerebrospinal fluid cytology, and tumour markers in cerebrospinal fluid were negative. Tumour response to initial radiotherapy was complete in three patients and partial in three patients. Recurrences were treated with interstitial irradiation with iodine-125 seeds in four instances, repeat radiotherapy when time elapsed was more than five years in one instance, with surgical resection in two instances, and chemotherapy in two instances. The diagnostic and therapeutic effectiveness of this management strategy is assessed. There were no complications related to surgical procedures. The median follow-up time was 48 months (range 14-70 months). Five patients were alive at 14, 45, 51, 57, and 70 months of follow-up. One patient died of disease at 28 months following diagnosis. The overall survival rate was 80 % +/- 17.89 % at 28 months. The results of this study suggest that this non-resective treatment approach is acceptable as an initial treatment alternative to radical surgical resection of pineoblastomas.

A serial CT scan and MRI verification of diffuse cerebrospinal gliomatosis: a case report with stereotactic diagnosis and radiological confirmation.

Gliomatosis cerebri is an infrequent tumor of neuroepithelial origin presenting with deterioration of cognitive functions, behavioral and mental changes, motor weakness, headache, and seizures. Laboratory data are unconclusive. MRI appears to be the imaging modality of choice and mainly reveals a bilateral and diffuse infiltration of midline adjacent brain structures whose anatomical configuration remain intact. MRI- or CT-guided stereotactic biopsy is advised as the diagnostic procedure in suspected cases. A 9-year-old girl with diffuse cerebrospinal gliomatosis, investigated with sequential cranial CT scans, and MRI-verified spinal cord involvement is reported, and the corresponding literature is reviewed.