Endovascular therapy outcome in isolated posterior cerebral artery occlusion strokes: A multicenter analysis of the Swiss Stroke Registry.

PURPOSE: There is little data on the safety and efficacy of endovascular treatment (EVT) in comparison with intravenous thrombolysis (IVT) in acute ischemic stroke due to isolated posterior cerebral artery occlusion (IPCAO). We aimed to investigate the functional and safety outcomes of stroke patients with acute IPCAO treated with EVT (with or without prior bridging IVT) compared to IVT alone. METHODS: We did a multicenter retrospective analysis of data from the Swiss Stroke Registry. The primary endpoint was overall functional outcome at 3 months in patients undergoing EVT alone or as part of bridging, compared with IVT alone (shift analysis). Safety endpoints were mortality and symptomatic intracranial hemorrhage. EVT and IVT patients were matched 1:1 using propensity scores. Differences in outcomes were examined using ordinal and logistic regression models. FINDINGS: Out of 17,968 patients, 268 met the inclusion criteria and 136 were matched by propensity scores. The overall functional outcome at 3 months was comparable between the two groups (EVT vs IVT as reference category: OR = 1.42 for higher mRS, 95% CI = 0.78-2.57, p = 0.254). The proportion of patients independent at 3 months was 63.2% in EVT and 72.1% in IVT (OR = 0.67, 95% CI = 0.32-1.37, p = 0.272). Symptomatic intracranial hemorrhages were overall rare and present only in the IVT group (IVT = 5.9% vs EVT = 0%). Mortality at 3 months was also similar between the two groups (IVT = 0% vs EVT = 1.5%). CONCLUSION: In this multicenter nested analysis, EVT and IVT in patients with acute ischemic stroke due to IPCAO were associated with similar overall good functional outcome and safety. Randomized studies are warranted.

The infratemporal fossa approach for nasopharyngeal tumors.

The technique and results of the infratemporal fossa surgical removal of carcinomas and juvenile angiofibromas of the nasopharynx are presented. Effective palliative removal of T4 and radical removal of T1 and T2 nasopharyngeal carcinomas was achieved. A classification of juvenile nasopharyngeal angiofibroma is presented. The infratemporal fossa approach allows radical removal of type III tumors and subtotal removal of type IV tumors. If residual tumor has to be left back in the cavernous sinus, irradiation is used to stop further growth of the tumor. If radiotherapy fails the neurosurgical removal of the intracranial portion of the tumor is indicated.

Management of the internal carotid artery in surgery of the skull base.

Management of the internal carotid artery in skull-base surgery can be a difficult problem when disease involves this vessel or resection is anatomically limited by it. The recent radiologic development of the detachable balloon catheter has permitted occlusion of the internal carotid artery in a controlled setting prior to any surgical procedure. An obvious prerequisite to using this technique is the demonstration of adequate collateral blood flow to the brain. Patients are evaluated with arteriography and temporary arterial balloon occlusion while monitoring physical signs and electroencephalography (EEG). Although usually performed preoperatively, internal carotid artery occlusion is needed intraoperatively on occasion. This essential adjuvant technique for the skull-base surgeon will be detailed along with its indications and limitations in 24 patients.

Malignant transformation of a nasopharyngeal angiofibroma.

The malignant transformation of a nasopharyngeal angiofibroma is a rare occurrence. This report describes the development of a fibrosarcoma in a patient over a 20-year period after four surgical procedures and two courses of radiation therapy to control a nasopharyngeal angiofibroma. A review of the literature revealed similar descriptions of this problem. Radiation likely plays a major role in causing the malignant change. An initial complete surgical excision can prevent recurrence of a nasopharyngeal angiofibroma as well as sarcomatous transformation. With the availability of surgical procedures that can completely and safely resect almost all nasopharyngeal angiofibromas, radiation therapy can be avoided.

Histopathology of the facial nerve after longitudinal temporal bone fracture.

The temporal bone histopathology in a patient who suffered repeated head trauma and a longitudinal temporal bone fracture shows unusual features associated with the facial nerve. In the distal meatal segment, a type of traumatic neuroma was found with disorganized nerve bundles and distinct areas of Schwann's cell proliferation but lacking fibrosis. Periosteal new bone formation in the labyrinthine segment narrows the fallopian canal and protrudes into the nerve, which completely fills the canal. The tympanic and mastoid segments of the nerve show severe degeneration of nerve fibers and an increase in connective tissue between fascicles. An attempted facial nerve decompression did not reach the area of primary pathology in the labyrinthine and meatal segments of the nerve, which could have been exposed by the transtemporal supralabyrinthine approach.

Jugular foramen peripheral nerve sheath tumors.

Though jugular foramen nerve sheath tumors are uncommon, they involve a critical area of the skull base. Therefore, a precise classification system is needed to accurately define the extent of these tumors and reflect their surgical management. A series of seven cases is reviewed incorporating such a classification system to illustrate the management of these lesions using the infratemporal fossa type A approach.

Update on the infratemporal fossa approaches to nasopharyngeal angiofibroma.

OBJECTIVES: Review of preoperative evaluation, surgical management, and outcome of patients operated on for nasopharyngeal angiofibroma using lateral infratemporal fossa approaches. STUDY DESIGN: Retrospective review of 20 patients with either extensive (Fisch class IIIa to IVb, n = 17) or less massive (Fisch class II, n = 3) nasopharyngeal angiofibromas. Analysis of preoperative radiologic classification and angiography and description of indications and surgical techniques of the infratemporal fossa approaches types C and D. Evaluation of the surgical morbidity and radicality of tumor removal. METHODS: Clinical data were obtained from medical records from 1987 to 1994. Tumor classification, preoperative symptoms, type of surgery, and neuroradiologic and surgical complications were evaluated. The completeness of tumor removal was assessed using postoperative magnetic resonance imaging. RESULTS: Temporary visual disturbance or headache, or both, was seen in two of 20 patients after superselective tumor embolization, and further visual diminution was observed in one of six patients after balloon occlusion of the internal carotid artery. Radical resection was obtained in 80% of the cases. The infratemporal fossa type C approach was used in 16 of the cases, with type D approaches used in the other four. There were no deaths. The major morbidity was the conductive hearing loss associated with the type C approach. CONCLUSIONS: Preoperative embolization (and balloon occlusion in selected cases) remains an important adjunct with minimal morbidity. The lateral infratemporal fossa approaches yield a high rate of radical tumor removal (80%) and a low rate of recurrence (6%). If applicable, the type D approach avoids the conductive hearing loss but allows direct tumor access into the infratemporal and pterygopalatine fossae.

Intratemporal facial nerve anastomosis: a temporal bone study.

The temporal bone findings in a patient who suffered a transverse temporal bone fracture and subsequently underwent intratemporal facial nerve anastomosis are presented. The patient returned a year after surgery with otorrhea and partial return of facial function that was documented clinically, and by electromyograph 12 days before death. The temporal bone shows breakdown of the posterior external canal wall and infection of the surgical cavity. At the facial nerve anastomosis, there is a fibrosis and lack of myelination in the few regenerating nerve fibers. These results demonstrate a seldom-mentioned complication of the translabyrinthine approach, and suggest changes in the technique of facial nerve anastomosis to improve the results.

Intratemporal facial nerve perineurioma.

Forty-two cases of perineurioma have been reported in the literature. This report adds the first intratemporal facial nerve perineurioma to the literature and reviews the others. Unlike schwannoma and neurofibroma, the histological features of perineurioma demonstrate onion bulb-like structures with a strong positive immunoreactivity for epithelial membrane antigen. The clinical history of gradual facial nerve paresis was 15 years in the case presentation and the clinical diagnosis of tumor was overlooked.

The histopathological and clinical features of irradiated and nonirradiated temporal paragangliomas.

This study was undertaken to determine the effects of radiation on temporal paragangliomas. The histological features were assessed in a blind fashion from 20 surgical specimens obtained from 20 patients, half of whom received radiotherapy. All patients had progressive temporal paragangliomas and were selected on a random basis for this study. The derived data clearly identify the unpredictable response of these tumors to radiation and supports our contention that surgery is the preferred form of treatment for temporal paragangliomas even after radiation therapy. Analysis of clinical histories reveals that previous radiation therapy is associated with a greater operative blood loss and a longer mean postoperative hospital stay due to delayed healing. Despite this, there was no mortality or serious morbidity from surgery.

Long-term results of surgery for temporal bone paragangliomas.

OBJECTIVES: Assessment of the long-term results of surgery for temporal bone paragangliomas with special consideration of the patient's ability to cope with the functional deficits. STUDY DESIGN: Retrospective review of 36 patients who had undergone resection of a temporal bone paraganglioma 10 to 15 years previously. Assessment of the patients' subjective view of the functional outcome and quality of life by a questionnaire. METHODS: Clinical records were reviewed regarding size of tumor, technique of surgery, supportive therapy, and tumor recurrence. Patients were sent a 50-item questionnaire evaluating their quality of life and the preoperative and postoperative function of cranial nerves VII through XII. RESULTS: A complete tumor removal was achieved in 30 patients (83%). There was only one tumor recurrence. The major negative effects of surgery involved hearing and dysphagia, which deterioriated in 14 and 12 patients, respectively. Thirty-five of the 36 patients (97%) reported that, despite deterioration, the cranial nerve deficits were still acceptable. Seventy-five percent of the patients regained their preoperative quality of life and 97% returned to their previous occupation in 1 to 2 years. CONCLUSIONS: The otologic extradural approach allowed complete tumor removal in 83%, with minimal perioperative morbidity. No surgically induced central nervous system lesions occured. Tracheostomy was avoided and all patients resumed oral feeding. Full rehabilitation after removal of class C and CD paragangliomas may take 1 to 2 years. However, the fact that 97% of the patients finally resumed normal social life showed the ability of most patients to cope with the sequelae of surgery even in class C and CD paragangliomas.

The surgical management of extensive nasopharyngeal angiofibromas with the infratemporal fossa approach.

Large juvenile nasopharyngeal angiofibromas are a therapeutic challenge because of their relation to major vasculature and cranial nerves at the base of the skull, and their propensity for recurrence. A classification scheme based on the growth pattern of this tumor is proposed to help the surgeon choose a procedure to access this lesion. This report describes the results obtained with the surgical removal of large (class III and IV) nasopharyngeal angiofibromas through the infratemporal fossa approach. Fourteen patients were cured and one individual developed a recurrence which was totally removed at a second procedure. Surgical morbidity was minimal and there was no mortality. Radiation therapy was necessary in only one patient who had tumor infiltration of the cavernous sinus.

Evaluation of eardrum laser doppler interferometry as a diagnostic tool.

OBJECTIVES: Laser Doppler interferometry (LDI) of the eardrum allows noncontact optical analysis of its vibrations in response to sound. Although LDI has been widely used in research, it has not yet been introduced into clinical practice as an adjunctive test for otological workup. The aim of this study was to evaluate LDI as a diagnostic tool in the clinical sphere. STUDY DESIGN: Prospective. METHODS: A measurement system was developed based on a commercially available scanning He-Ne laser Doppler interferometer. The study included 129 eardrums of 79 subjects that were divided into 3 groups: 1) normal subjects and 2) patients with sensorineural and 3) conductive hearing loss (HL). All the patients suffering from conductive HL underwent ossiculoplasty, which allowed confirmation of the final diagnosis, and patients were assigned accordingly to the subgroups malleus fixation, incus luxation, and stapes fixation. RESULTS: The modified LDI system allowed bilateral evaluation of a subject within 30 minutes. No significant difference between normal subjects and patients having sensorineural HL were found. However, it was possible to distinguish between normal subjects and patients with conductive HL. Furthermore, the system had the ability to differentiate between various middle ear diseases. These groups differed statistically significantly in terms of manubrium vibration amplitude and resonance frequency. In malleus fixation significant differences in tympanic membrane movement patterns were found. CONCLUSIONS: Our LDI is applicable in clinical otological practice and serves as a valuable addition to the routine audiological investigations for preoperative evaluation of the mobility and integrity of the ossicular chain.

Multicentric eighth cranial nerve schwannoma.

To our knowledge, only 3 histopathologically proved cases of multicentric eighth cranial nerve schwannoma have been described in the literature since 1981. We describe a patient with 2 isolated eighth cranial nerve schwannomas arising separately from the left cochlea and internal auditory canal. These 2 tumors were diagnosed using magnetic resonance imaging prior to resection, and the diagnosis was further confirmed by intraoperative findings and histopathologic analysis. The genetic molecular basis and clinical features of this rare tumor have been overlooked. The value of the transotic approach for total tumor removal is emphasized.

The comparison of facial grading systems.

To evaluate the relative merits of objective and subjective facial grading systems, we compared the results obtained with the Fisch, House, and Linear Measurement grading techniques in 12 subjects exhibiting varying degrees of palsy. Although most grading systems correlate well with each other, systems can vary dramatically in patient discrimination, interobserver variability, relative underrating and overrating, properties of nerve function selected, objectivity, and clinical definition. Objective and subjective data offer selective advantages.

Primary and revision surgery (selective neurectomy) for facial hyperkinesia.

Symptomatic relief for hyperkinetic movements of facial musculature can be obtained by selective neurectomy of the peripheral divisions of the facial nerve with preservation of the frontal branch. Hemifacial spasm and blepharospasm represent the most common forms of facial hyperkinesia. Satisfactory results using the described technique on 191 patients were achieved in 74% of the patients with hemifacial spasm and blepharospasm in the follow-up period of one to 12 years. In hemifacial spasm, 80% were relieved after a single operation, and 95% were relieved after revision surgery. There were no major postoperative complications. Minor complications included insufficient lid closures in 1.5% of the patients and delayed wound healing with minor salivary fistulas that closed spontaneously in 7% of the patients. Resection of all fibers innervating the orbicularis oculi muscle is essential in preventing recurrence.

A morphological study of the effect of the Cavitron ultrasonic surgical aspirator system near human peripheral nerves.

The Cavitron ultrasonic surgical aspirator system was used to clear superficial tissue from the greater auricular nerve in four human subjects. Following stimulation, the nerves were removed together with an untreated section and processed for examination by light microscopy. Significant damage had been sustained by these nerves, which was not apparent in the control sections. Disruption of the perineurium, intraneural hemorrhage, endoneural edema, and degenerative changes of the myelinated nerve fibers were seen. Damage to neural tissue was evident 0.5 to 1.5 mm in advance of the point of contact with the cutting tip.

Endolymphatic pressure in experimental hydrops.

Perilymphatic and endolymphatic pressures were consecutively measured by means of a servomechanical nulling pressure system through the round window and basilar membrane one to 2.5 months after obliteration of the left endolymphatic sac and duct in seven guinea pigs. The position of the pipette was monitored by the simultaneous recording of the direct current potential through the micropipette used for the pressure measurement. (1) The perilymphatic and endolymphatic pressures of the control ears were equal. (2) The histological evaluation showed that the ears operated on had a significantly greater endolymphatic space than the control ears. (3) The endolymphatic pressure of the ear operated on was significantly higher (0.78 +/- 0.32 mm Hg) than that of the perilymph. (4) The endolymphatic direct current potential was equal in both ears.

Histology of synthetic ossicular prostheses.

Thirty-three synthetic middle ear prostheses removed after two to 99 months of implantation were examined histologically. All prostheses were infiltrated by fibroblasts, capillaries, collagen fibrils, and multinucleate foreign body giant cells. Although some of the giant cells contained tiny particles of the prosthetic material, there was no evidence of erosion or engulfment of larger particles of the prosthesis or structural dissolution of the prosthesis. New histologic findings were aseptic necrosis and focal calcification in the interior of some of the prostheses.

Analysis of formulation and food effect on the absorption of metoclopramide.

OBJECTIVES: Assessment of the relative and absolute bioavailability of immediate release and sustained release formulations of metoclopramide. Assessment of the effect of a high-fat meal on the pharmacokinetics of sustained release metoclopramide. MATERIAL AND METHODS: In a balanced 4-way crossover study in 16 healthy male volunteers, a sustained release (SR) formulation of metoclopramide was compared with a solution for injection (A) and an immediate release tablet (B). The SR formulation was administered after a fasting period (C) as well as after a high-fat meal (D). A single dose of 30 mg metoclopramide was investigated in each treatment. Metoclopramide concentrations were determined by HPLC. RESULTS: The absolute bioavailability of the sustained release formulation (fasting state) was 58% and thus about 17% lower than the bioavailability of the immediate release formulation. Comparing the treatments C (sustained release, fasting state) and D (sustained release, high-fat meal) no significant influence of food on the absorption of sustained release metoclopramide could be detected.