Electrical cortical stimulation for treatment of intractable epilepsy originating from eloquent cortex: surgical accuracy and clinical efficacy.

BACKGROUND: Electrical cortical stimulation is shown effective in treating patients with drug-resistant epilepsy. We demonstrated how detailed procedures of pre- and intra-operative planning of cortical stimulation implantation may influence the results of seizure reduction rate. METHODS: To confirm the precision of subdural grids covering the epileptogenic foci in the eloquent regions, pre- and intra-operative video-electroencephalography (VEEG) were performed in patients with drug-resistant epilepsy during a 4-day 24-h monitoring. The localization of the grid was determined via 3D reconstruction imaging of subdural electrodes co-registered onto the patient's cortex. A final quadripolar lead in cyclic stimulation mode was then placed and secured on the target cortex area. Post-operative 3D CT ensured the accurate location of stimulation lead without any misplacement. Bipolar cyclic stimulation and post-implantation VEEG were performed for 7 days. Patients were discharged and followed up regularly for parameters adjustment and recording of seizure outcomes. RESULTS: Eight patients received chronic cortical stimulation implantations between February 2003 and December 2017. The mean age of these patients was 21.1 years old and the average post-operative follow-up was 77.3 months. Comparisons of their seizure frequency at baseline and during the postoperative period revealed a mean reduction in seizures of 60.4% at the first year and 65.6% at the second year. CONCLUSIONS: Pre-surgical planning enhanced the accuracy of electrode placement and led to a favorable seizure reduction rate. Our report confirms that electrical cortical stimulation with detailed implantation procedures is safe and effective for patients with drug-resistant epilepsy originating from eloquent cortex.

Correlations between clinical hormone change and pathological features of pituicytoma.

PURPOSE: Pituicytoma is a rare low-grade glioma arising from the pituicytes of the posterior pituitary. To date, the clinical and pathological correlates of pituicytoma have not been investigated. This study was thus designed to examine the correlation between pituicytoma and the normal pituitary gland. METHODS: The records of patients who underwent pituitary surgery at Chang Gung Memorial Hospital in Linkou, Taiwan between 2000 and 2016 were reviewed. Patients who received a pathological diagnosis of pituicytoma were included; however, those with inadequate specimens for pathological study were excluded. Clinical information, including patients' presenting symptoms, serum hormone levels, neuroimages, and specimens, were collected. Hematoxylin and eosin stains and immunohistochemical (IHC) stains were performed for differential diagnosis. RESULTS: Among the 1532 patients who underwent pituitary surgery, nine (0.59%) received a pathological diagnosis of pituicytoma. Two patients were excluded due to inadequate specimens. Among the seven remaining patients, six presented with hormone changes. The IHC stains revealed that pituicytoma has no secretory function; however, the resected pituitary glands showed positive results for hormone change. Coexisting pituicytoma and adrenocorticotropic hormone adenoma were identified in one patient with a diagnosis of Cushing disease. CONCLUSIONS: Pituicytoma revealed a negative endocrine secretory function through IHC staining. Additionally, pituicytoma is associated with hypersecretion of the pituitary gland both clinically and pathologically. Diagnosing pituicytoma before pathological confirmation is difficult because the tumour may present with hormone dysfunction. Therefore, IHC staining of specimens is useful to exclude the possibility of coexisting pituicytoma and pituitary adenoma.

Effect of ventilation rate on air cleanliness and energy consumption in operation rooms at rest.

The interrelationships between ventilation rate, indoor air quality, and energy consumption in operation rooms at rest are yet to be understood. We investigate the effect of ventilation rate on indoor air quality indices and energy consumption in ORs at rest. The study investigates the air temperature, relative humidity, concentrations of carbon dioxide, particulate matter (PM), and airborne bacteria at different ventilation rates in operation rooms at rest of a medical center. The energy consumption and cost analysis of the heating, ventilating, and air conditioning (HVAC) system in the operation rooms at rest were also evaluated for all ventilation rates. No air-conditioned operation rooms had very highest PM and airborne bacterial concentrations in the operation areas. The bacterial concentration in the operation areas with 6-30 air changes per hour (ACH) was below the suggested level set by the United Kingdom (UK) for an empty operation room. A 70% of reduction in annual energy cost by reducing the ventilation rate from 30 to 6 ACH was found in the operation rooms at rest. Maintenance of operation rooms at ventilation rate of 6 ACH could save considerable amounts of energy and achieve the goal of air cleanliness.

Different perceptions of narrative medicine between Western and Chinese medicine students.

BACKGROUND: Western medicine is an evidence-based science, whereas Chinese medicine is more of a healing art. To date, there has been no research that has examined whether students of Western and Chinese medicine differentially engage in, or benefit from, educational activities for narrative medicine. This study fills a gap in current literature with the aim of evaluating and comparing Western and Chinese Medicine students' perceptions of narrative medicine as an approach to learning empathy and professionalism. METHODS: An initial 10-item questionnaire with a 5-point Likert scale was developed to assess fifth-year Western medical (MS) and traditional Chinese medical (TCMS) students' perceptions of a 4-activity narrative medicine program during a 13-week internal medicine clerkship. Exploratory factor analysis was undertaken. RESULTS: The response rate was 88.6% (412/465), including 270 (65.5%) MSs and 142 (34.5%) TCMSs, with a large reliability (Cronbach alpha = 0.934). Three factors were extracted from 9 items: personal attitude, self-development/reflection, and emotional benefit, more favorable in terms of enhancement of self-development/reflection. The perceptions of narrative medicine by scores between the two groups were significantly higher in TCMSs than MSs in all 9-item questionnaire and 3 extracted factors. CONCLUSIONS: Given the different learning cultures of medical education in which these student groups engage, this suggests that undertaking a course in Chinese medicine might enhance one's acceptance to, and benefit from, a medical humanities course. Alternatively, Chinese medicine programmes might attract more humanities-focused students.

The effects of antiepileptic drugs on the growth of glioblastoma cell lines.

To determine the effects of antiepileptic drug compounds on glioblastoma cellular growth, we exposed glioblastoma cell lines to select antiepileptic drugs. The effects of selected antiepileptic drugs on glioblastoma cells were measured by MTT assay. For compounds showing significant inhibition, cell cycle analysis was performed. Statistical analysis was performed using SPSS. The antiepileptic compounds selected for screening included carbamazepine, ethosuximide, gabapentin, lamotrigine, levetiracetam, magnesium sulfate, oxcarbazepine, phenytoin, primidone, tiagabine, topiramate, valproic acid, and vigabatrin. Dexamethasone and temozolomide were used as a negative and positive control respectively. Our results showed temozolomide and oxcarbazepine significantly inhibited glioblastoma cell growth and reached IC50 at therapeutic concentrations. The other antiepileptic drugs screened were unable to reach IC50 at therapeutic concentrations. The metabolites of oxcarbazepine were also unable to reach IC50. Dexamethasone, ethosuximide, levetiracetam, and vigabatrin showed some growth enhancement though they did not reach statistical significance. The growth enhancement effects of ethosuximide, levetiracetam, and vigabatrin found in the study may indicate that these compounds should not be used for prophylaxis or short term treatment of epilepsy in glioblastoma. While valproic acid and oxcarbazepine were effective, the required dose of valproic acid was far above that used for the treatment of epilepsy and the metabolites of oxcarbazepine failed to reach significant growth inhibition ruling out the use of oral oxcarbazepine or valproic acid as monotherapy in glioblastoma. The possibility of using these compounds as local treatment is a future area of study.

Neurenteric cysts: risk factors and management of recurrence.

BACKGROUND: Neurenteric cysts are rare central nervous system lesions with excellent outcome after total excision. The authors report their experience in the management of these lesions, especially if recurrence occurs. Risk factors of recurrence were analyzed, which have never been reported according to the literature review. METHODS: Twelve patients underwent surgical treatment for neurenteric cysts from April 1998 to July 2015. We retrospectively reviewed the clinical, radiological, operative, and pathological findings for these patients. Correlations between clinical characteristics and recurrence were analyzed. RESULTS: This series included six intracranial and six intraspinal cases. Total resection was achieved in 4 of the 12 cases and partial resection in 8. Six of the patients that underwent partial resection suffered from recurrence, and an additional operation was needed in five. Three of the recurrent intracranial lesions had refractory symptoms and were finally controlled through cyst-peritoneal or ventricle-peritoneal shunts. Risk factors of recurrence were revealed as age ≦30 years old (p = 0.02), subtotal resection in the first operation (p = 0.01), and size of supratentorial NECs >30 ml (p = 0.04). Two-thirds of recurrences occurred in the first 2 years after treatment. CONCLUSIONS: NECs express high recurrence rates when total excision cannot be achieved. The preoperative diagnosis error plays a major role leading to an incorrect surgical strategy and recurrence. MRI with FLAIR and DWI is recommended to improve the preoperative diagnosis. Although timely reoperation is indicated for symptomatic recurrence, adhesion may cause reoperation to become more challenging. C-P or V-P shunts are suggested as the second-line treatment, resulting in excellent prognosis. Patients with mucin-secreting cells noted histologically are susceptible to recurrence.

Low and High Frequency Hippocampal Stimulation for Drug-Resistant Mesial Temporal Lobe Epilepsy.

OBJECTIVE: Electrical stimulation of the hippocampus offers the possibility to treat patients with mesial temporal lobe epilepsy (MTLE) who are not surgical candidates. We report long-term follow-up results in five patients receiving low or high frequency hippocampal stimulation for drug-resistant MTLE. MATERIALS AND METHODS: The patients underwent stereotactic implantation of quadripolar stimulating electrodes in the hippocampus. Two of the patients received unilateral electrode implantation, while the other three received bilateral implantation. Stimulation of the hippocampal electrodes was turned ON immediately after the implantation of an implantable pulse generator, with initial stimulation parameters: 1 V, 90-150 µs, 5 or 145 Hz. The frequency of seizures was monitored and compared with preimplantation baseline data. RESULTS: Two men and three women, aged 27-61 years were studied, with a mean follow-up period of 38.4 months (range, 30-42 months). The baseline seizure frequency was 2.0-15.3/month. The five patients had an average 45% (range 22-72%) reduction in the frequency of seizures after hippocampal stimulation over the study period. Low frequency hippocampal stimulation decreased the frequency of seizures in two patients (by 54% and 72%, respectively). No implantation- or stimulation-related side effects were reported. CONCLUSIONS: Electrical stimulation of the hippocampus is a minimally invasive and reversible method that can improve seizure outcomes in patients with drug-resistant MTLE. The optimal frequency of stimulation varied from patient to patient and therefore required individual setting. These experimental results warrant further controlled studies with a large patient population to evaluate the long-term effect of hippocampal stimulation with different stimulation parameters.

Raised Proinflammatory Cytokine Production Within Cerebrospinal Fluid Precedes Fever Onset in Patients With Neurosurgery-Associated Bacterial Meningitis.

OBJECTIVE: The objective of the present study was to determine whether selective inflammatory cytokine concentrations within cerebrospinal fluid are useful markers for the differential diagnosis of aseptic and bacterial meningitis within neurosurgical patients. DESIGN: Prospective, open-label, observational, cohort study. SETTING: Neurosurgical ICU, Chang Gung Memorial Hospital. PATIENTS: Thirty-two consecutive neurosurgical patients who had postoperative fever following external ventricular drain insertion for the treatment of brain injury underwent serial cerebrospinal fluid cytokine analysis pre and post fever to determine the value of such markers in ascertaining the differential diagnosis of meningitis. INTERVENTION: Cerebrospinal fluid samples were collected on the day of fever onset, as well as on day 2 and 4 pre and post fever development. Tumor necrosis factor-α, interleukin-1ß, interleukin-6, interleukin-8, transforming growth factor-ß, and procalcitonin were subsequently analyzed using enzyme-linked immunosorbent assay analysis techniques. MEASUREMENT AND MAIN RESULTS: Inflammatory marker levels were compared among febrile aseptic, bacterial, and nonmeningitis patients to determine cerebrospinal fluid inflammatory changes over time. Significant increases in cerebrospinal fluid tumor necrosis factor -α, interleukin-1ß, interleukin-6, and interleukin-8 levels were observed within patients with bacterial meningitis at fever onset, which was not evident in aseptic or nonmeningitis patients. Furthermore, significant increases in cerebrospinal fluid tumor necrosis factor-α, interleukin-1ß, interleukin-6, and interleukin-8 levels were detected as early as 4 days prior to fever onset within patients with bacterial meningitis when compared with both aseptic and nonmeningitis groups. Interestingly, procalcitonin was only significantly increased in patients with bacterial meningitis on the fourth day post fever. CONCLUSION: The present study suggests that raised cerebrospinal fluid tumor necrosis factor -α, interleukin-1ß, and interleukin-8 in a temporal manner may indicate early bacterial meningitis development in neurosurgical patients, enabling earlier diagnostic certainty and improved patient outcomes.

Corpus callosum involvement and postoperative outcomes of patients with gliomas.

Corpus callosum involvement is associated with poorer survival in high grade glioma (HGG), but the prognostic value in low grade glioma (LGG) is unclear. To determine the prognostic impact of corpus callosum involvement on progression free survival (PFS) and overall survival (OS) in HGG and LGG, the records of 233 glioma patients treated from 2008 to 2011 were retrospectively reviewed. Preoperative magnetic resonance (MR) images were used to identify corpus callosum involvement. Age, sex, preoperative Karnofsky performance scale, postoperative Eastern Cooperative Oncology Group (ECOG) score and extent of resection (EOR) were evaluated with respect to PFS and OS. The incidence of corpus callosum involvement was similar among HGG (14 %) and LGG (14.5 %). Univariate analysis revealed that PFS and OS were significantly shorter in both WHO grade II and grade IV glioma with corpus callosum involvement (both, p < 0.05). Multivariate analysis showed that grade II glioma with corpus callosum involvement have shorter PFS (p = 0.03), while EOR, instead of corpus callosum involvement (p = 0.16), was an independent factor associated with PFS in grade IV glioma (p < 0.05). Corpus callosum involvement was no longer significantly associated with OS after adjusting age, gender, EOR, preoperative and postoperative performance status (p = 0.16, 0.17 and 0.56 in grade II, III and IV gliomas, respectively). Corpus callosum involvement happened in both LGG and HGG, and is associated with lower EOR and higher postoperative ECOG score both in LGG and HGG. Corpus callosum involvement tends to be an independent prognostic factor for PFS in LGG, but not for OS in LGG or in HGG.

Linear accelerator stereotactic radiosurgery in the management of intracranial arteriovenous malformations: long-term outcome.

BACKGROUND: Arteriovenous malformation (AVM) is one of the cerebrovascular diseases that bear a high risk of hemorrhage. The treatment modalities include microsurgical resection, endovascular embolization, stereotactic radiosurgery, or combinations that vary widely. Several large series have been reported, while data from Asian populations were few. The aim of this study was to examine the efficacy of linear accelerator stereotactic radiosurgery (LINAC SRS) for the treatment of intracranial AVMs, to evaluate the hemorrhage rate and to analyze associated factors. METHODS: One hundred and sixteen patients with AVM were treated with LINAC SRS in a single institute between September 1994 and May 2005 and were retrospectively evaluated. The demographics of patients, clinical characteristics of AVM, the treatment modalities, and the parameters of the LINAC SRS were analyzed. Delayed toxicity and hemorrhage rate after treatment were also evaluated. The AVM obliteration and bleed rates were calculated using the Kaplan-Meier method and Cox regression analyses. RESULTS: The efficacy rate with total obliteration after treatment was 81.9% (95 of 116 patients). The median interval to achieve total obliteration was 49 months. Microsurgical resection combined with SRS for residual AVMs achieved better obliteration rates compared to SRS alone (statistically significant, p = 0.001), while no significant difference was found between the embolization group and the group with no prior treatment (p = 0.895). The Spetzler-Martin grade of AVM is a relative factor of obliteration, higher grades resulting in a worse outcome (p = 0.009). Obliteration was significantly influenced by AVM volume in univariate analysis (p = 0.034), and volume <5 cm(3) contributed to improved obliteration (p = 0.01). There was no statistically significant difference in the hemorrhagic rate and the complication rate between ruptured and unruptured AVMs, while the unruptured group had a higher obliteration rate (p = 0.024). The annual hemorrhage rate after LINAC SRS treatment was 1.9%. The bleeding rate was 3.3% in the first year after radiosurgery, 2.1% in the second year, 1.9% between the second and fifth year, and 1.5% between the fifth and tenth year. Patients with hemorrhagic events before radiosurgery appeared to have a higher rebleeding risk during the latency period. Twenty-three patients (19.8%) had late adverse effects with regard to posttreatment radiological follow-up, but only 1 (0.8%) had newly developed neurological deficits. CONCLUSION: LINAC SRS achieved a high obliteration rate and reduced the risk of hemorrhage effectively in ruptured and unruptured intracranial AVMs. Prior microsurgical resection provided better outcome, while embolization showed no benefit. Adverse effects after treatment are acceptable and require long-term follow-up.

Long-term result of vocal cord paralysis after anterior cervical disectomy.

PURPOSE: Anterior cervical disectomy and fusion (ACDF) is a highly effective and safe method for spinal cord and cervical root decompression. However, vocal cord paralysis (VCP) remains an important cause of postoperative morbidity. The true incidence and recovery course of postoperative VCP is still uncertain. This study is a report on VCP after ACDF to evaluate the incidence, recovery course, and possible risk factors. METHODS: From 2004 to 2008, 1,895 consecutive patients underwent ACDF in our hospital and were followed up for at least 3 years. All surgeons were well trained and used a right-sided exposure. Prolonged VCP, where patients suffered from postoperative VCP lasting more than 3 months, was recorded and analyzed. RESULTS: In this retrospective study, 9 of the 1,895 patients (0.47%) documented prolonged VCP lasting over 3 months. Six of the nine patients had total recovery within 9 months. Only three patients (0.16%) still had symptoms even after 3 years postoperatively. All symptoms of VCP, except hoarseness, could be improved. After matching with 36 non-VCP patients, no differences with regard to longer operative or anesthesia time, shorter neck, obesity, and prevertebral edema. All cases of prolonged course of postoperative VCP occurred in patients who underwent exposure at the C67 level. CONCLUSION: In our study, only 0.47% documented prolonged postoperative VCP, while most patients recovered within 9 months. However, if symptoms last longer, there could be almost permanent VCP (0.16%). In our study, choking and dysphagia subsided mostly within 6 months, but hoarseness remained. The exposure of the C67 level obviously was a risk factor for postoperative VCP.

The impact of low-frequency stimulation of subthalamic region on self-generated isometric contraction in patients with Parkinson's disease.

Growing evidence suggests that spontaneous oscillatory low-frequency synchronization in the subthalamic nuclei (STN) may modulate motor performance in patients with Parkinson's disease (PD). To explore this in more detail, 15 PD patients chronically implanted with deep brain stimulation (DBS) electrodes in both STN were stimulated bilaterally at 5, 10, 20, 50 and 130 Hz and the effects of the DBS on self-initiated isometric elbow flexion (FLEX) and finger pinch (PINCH) were compared to performance without DBS. Baseline performance was very much impaired. Peak force was significantly greater during 130 and 10 Hz stimulation when compared to no stimulation in both tasks. Cumulative sums of the changes in mean rising force and peak force in the two tasks upon stimulation at 10 and 20 Hz demonstrated that patients improved their performance on stimulation, except for those with the best performance off stimulation who deteriorated with stimulation at 20 Hz. Thus, no effect was detected with 20 Hz stimulation at the group level. The current study highlights the need to consider the baseline performance of a subject in a given task when determining the effects of low-frequency STN stimulation in PD patients. It also demonstrates that stimulation at 10 Hz can improve motor function in subjects with poor baseline function.

Ganglion cyst of the cruciate ligament with atlantoaxial subluxation.

BACKGROUND: Ganglion cysts of the cruciate ligament are rare and sometimes asymptomatic. The authors present three cases of ganglion cysts of the cruciate ligament with atlantoaxial subluxation, which has rarely been reported previously. METHODS: Generally, ganglion cysts of the cruciate ligament are reported as case reports. Several theories regarding the process of cyst formation and the development of treatment options have been described. However, trans-oral decompression with total removal of the cyst may be one of the options for treatment of this kind of disease. RESULTS: A retrospective review of three patients, two female and one male patient, with a mean age of 68 years was conducted. The operation performed was a trans-oral decompression with cyst removal for all patients. Clinical outcomes were evaluated after the operation. All patients underwent trans-oral decompression with total removal of the cyst, followed by posterior fusion and pathologic examination of the cyst, revealing myxoid stroma with an absence of synovial linings. CONCLUSION: The ganglion cysts and synovial cysts of the cruciate ligament are two different diseases with different presentation, pathogenesis, pathophysiology, and pathologic findings.

Balloon test occlusion of the internal carotid artery with stump pressure ratio and venous phase delay technique.

Balloon test occlusion (BTO) is crucial before sacrificing parent arteries. We proposed a simple paradigm combining clinical tolerance with venous phase technique and stump pressure ratio as a criterion for sufficient collateral flow. Internal carotid artery (ICA) occlusion was considered safe for asymptomatic patients who exhibited less than 2 seconds of venous phase delay or had a stump pressure ratio greater than 60%. A total of 37 BTO procedures were performed on 31 patients. Twenty-three patients were monitored clinically and 3 were symptomatic. Venous phase comparison was performed on 27 patients, and 5 failed the test. The stump pressure was measured in all patients, and 7 patients failed the test. In summary, 7 patients failed the BTO, of which 6 received high-flow bypass and 1 of these 6 were symptomatic and exhibited stump pressure ratios less than 60% in the second BTO procedure. Occlusion of the ICA was performed on 29 patients. Only 1 patient developed delayed vasospasm and brain infarction. Adequate collateral flow may be indicated by a stump ratio of 60% or greater with or without a high-flow bypass. Combined with clinical assessment and venous phase technique, ICA occlusion may be a safe option that does not result in delayed ischemic complications.

The intracranial volume pressure response in increased intracranial pressure patients: Part 1. Calculation of the volume pressure indicator.

BACKGROUND: The intracranial pressure (ICP) is usually continuously monitored in the management of patients with increased ICP. The aim of this study was to discover a mathematic equation to express the intracranial pressure-volume (P-V) curve and a single indicator to reflect the status of the curve. METHODS: Patients with severe brain damage who had bilateral external ventricular drainage (EVD) from December 2008 to February 2010 were included in this study. The EVD was used as drainage of CSF and ICP monitor. The successive volume pressure response [6] values were obtained by successive drainage of CSF from ICP 20-25 to 10 mmHg. Parabolic, exponential, and linear regression models were designed to have a single parameter as the indicator to determine the P-V curves. RESULTS: The mean of parameter "a" in the exponential equation is 1.473 ± 0.054; in the parabolic equation, it is 0.332 ± 0.061; and in the linear equation, it is 1.717 ± 0.209. All regression equations of P-V curves had statistical significance (p < 0.005). Parabolic and exponential equations are closer to the original ICP curve than linear equation (p < 0.005). There is no statistically significant difference between parabolic and exponential regressions. CONCLUSIONS: The P-V curve can be expressed with linear, parabolic, and exponential regression models in increased ICP patients. The parabolic and exponential equations are more accurate methods to represent the P-V curve. The single parameter in the three regression equations can be compared in different conditions of one patient in clinical practice.

Effect of valproic acid on the outcome of glioblastoma multiforme.

BACKGROUND: Glioblastoma multiforme (GBM) is the most aggressive type of primary brain tumor. It is a rapidly progressive, highly recurrent, fatal intracranial neoplasm, and the demand for novel treatment is urgent. Valproic acid (VPA) is a potential anticancer agent that belongs to a class of histone deacetylase (HDAC) inhibitors, targeting the epigenetic control of gene functions in cancer cells. This drug has been administered for the prevention or treatment of seizure disorder in GBM patients; therefore, a retrospective analysis may further our understanding of the effect of VPA on GBM patients. MATERIALS AND METHODS: A retrospective analysis of 102 patients with GBM was conducted to study the effects of VPA on disease outcome. Tumor samples from seven patients receiving VPA treatment between the first and second operations were obtained in order to verify the HDAC inhibitory activity of VPA in these patients. RESULTS: In univariate analysis, administration of VPA within 2 weeks of initial diagnosis seemed to confer a survival benefit. However, stratified analysis according to chemotherapy showed that VPA did not have significant impact on the GBM patients' overall survival. Analysis of tissue samples from these patients revealed that a small subset of patients had increased histone acetylation after VPA treatment. CONCLUSION: VPA treatment, when administered according to a protocol targeting seizure control, may result in HDAC inhibition in a small subset of patients, but does not significantly affect overall patient survival. Early administration of VPA as an adjunct to temozolomide chemotherapy may have its merits, but the optimal dosing schedule and target serum level require further investigation.

Delayed diagnosis of traumatic cervical subluxation in patients with mandibular fractures: a 5-year retrospective study.

BACKGROUND: Mandibular bone fracture associated with traumatic cervical subluxation is a rare injury. The diagnosis of a traumatic cervical subluxation is more easily delayed than other conditions in patients with mandibular bone fractures. The aim of this study is to investigate the incidence of traumatic cervical subluxation associated with mandibular bone fractures. METHODS: This is a retrospective cohort study of 653 consecutive emergency department patients with mandibular bone fractures investigated for evidence of concomitant traumatic cervical subluxation. RESULTS: This study reports on 7 patients (1.07%) with a diagnosis of traumatic cervical subluxation from a cohort of 653 with mandibular bone fractures as a result of motor vehicle accidents. Two of seven patients had their diagnosis made while in the emergency room, thus, 71.43% of these injuries were discovered on studies done up to 10 days after the trauma, including after surgical correction of the mandibular bone fracture. CONCLUSION: The importance of a thorough initial examination (both physical and radiologic) and suspicion of traumatic cervical subluxation in patients with mandibular bone fractures is worth emphasizing as delayed diagnosis and management could result in permanent neurologic injury. We suggest dynamic flexion-extension cervical radiographs and thin-slice computerized tomography scans in patients with mandibular fractures routine as an important and routine practice protocol.

Aneurysmal subarachnoid hemorrhage diagnosis with computed tomographic angiography and OsiriX.

PURPOSE: Recent advances in computed tomographic angiography (CTA) have resulted in its replacing digital subtraction angiography (DSA). However, CTA requires a powerful workstation and experienced technicians for image postprocessing. OsiriX, a free open-source medical imaging software with powerful three-dimensional (3D) capability, enables neurosurgeons to perform 3D rendering without extensive training. In this study, we examined the sensitivity and specificity of CTA with OsiriX as the primary diagnostic tool for intracranial aneurysms. METHOD: From May 2006 to March 2009, 121 patients with spontaneous subarachnoid hemorrhage (SAH) underwent CTA. The CTA source images were 3D rendered by neurosurgeons using OsiriX. All the possible locations for aneurysms were carefully reviewed. DSA was performed on every patient in any of the following conditions: for negative CTA findings, after surgical clipping of aneurysms or before transarterial embolization of aneurysms. RESULT: Of the 121 patients, 8 were excluded because DSA data were not available. In the remaining 113 patients, 20 patients had negative CTA findings. CTA with OsiriX detected 106 aneurysms in 93 patients, of which 103 were confirmed by DSA or postoperative DSA; 3 infundibular dilated pouches of small arteries were mistaken for aneurysms. Two anterior communicating artery aneurysms (1.5 mm and 1 mm) were missed by CTA from among all 113 patients. The sensitivity and specificity of CTA for detecting aneurysms on a per-patient basis were 98.9% and 100%, respectively. The sensitivity and specificity of CTA for detecting aneurysms on a per-aneurysm basis for detecting aneurysms were 98.1% and 86.3%, respectively. CONCLUSION: CTA with OsiriX enables accurate detection of intracranial aneurysms. Cerebral DSA should be reserved for those patients with negative CTA findings.

A hollow cylindrical PMMA strut for cervical spine reconstruction after cervical multilevel corpectomy.

STUDY DESIGN: Between January 2002 and December 2005, a prospective study was performed with 14 patients. The patients had cervical diseases and received more than 1 segment anterior cervical corpectomies. OBJECTIVES: We investigated the effectiveness of the hollow cylindrical polymethyl methacrylate (PMMA) strut with the autograft for fusion and reconstruction of the cervical spine after multiplelevel cervical corpectomy. SUMMARY OF BACKGROUND DATA: We usually used the titanium mesh cage to reconstruct the cervical spine after cervical corpectomy. A significant number of poor outcomes were noted. Because the mesh cage is very hard, it sinks into the vertebral body without the cortex. It is also difficulty to assess the fusion status. METHODS: A total of 14 patients (age range: 31 to 76 y) underwent anterior cervical corpectomy after fusion and reconstruction with cylindrical PMMA struts. Each patient was reinforced with anterior cervical plate fixation. Follow-up radiographic evaluation was comprised of plain lateral dynamic radiographs and computerized tomography (CT) scans. We evaluated the patients for cervical lordosis and vertebral body height on the basis of plain radiographs. The fusion status was evaluated with CT scans. Neurologic status was assessed preoperative and postoperatively using the Nurick's grading system. RESULTS: : The mean follow-up was 48.2 months (range: 28 to 70 mo). All patients showed spinal stability at 6 months follow-up on the basis of plain lateral dynamic radiograph results. Thirteen patients showed neurologic improvement with complete bony fusion in the 24-month reconstructed CT scans. There were no complications related to the hollow cylindrical PMMA strut. One patient had loosened screws and required a second operation. CONCLUSIONS: The cylindrical PMMA strut provides solid fusion and increased cervical lordosis and vertebral body height. There are few complications associated with the use of this strut, and neurologic recovery is satisfactory. The hollow cylindrical PMMA strut, combined with an anterior cervical plate, is a very successful surgical construct in these patients after long-segmental cervical corpectomy.

Cranioplasty using polymethyl methacrylate prostheses.

In this retrospective study we attempted to assess the clinical performance of prefabricated polymethyl methacrylate (PMMA) prostheses and to determine whether they outperform intra-operatively moulded PMMA prostheses in reducing operating time, blood loss and surgical complications in elective delayed cranioplasty operations, after decompressive craniectomy, to repair large (> 100 cm2) cranial defects. Patients (n=131) were divided into three groups according to the cranioplasty technique used. Group 1 patients received fresh frozen autograft bone that had been removed at the craniectomy and refrigerated at -80 degrees C. Group 2 included patients whose PMMA prosthesis was moulded intra-operatively. Group 3 patients received a custom-made prefabricated PMMA prosthesis manufactured using computer-aided design/computer-aided manufacturing (CAD/CAM). Group 2 patients required significantly more operating time than both group 1 (p<0.001) and group 3 (p<0.001) patients, but operating time did not differ significantly between groups 1 and 3 (p>0.05). Mean intra-operative blood loss was significantly higher in group 2 than in group 1 (p=0.015) but did not differ significantly between group 1 and group 3 (p>0.05). The infection rate associated with prefabricated PMMA prostheses was lower than that for intra-operatively moulded PMMA prostheses and was comparable to that for autograft bone flaps. A CAD/CAM PMMA prosthesis is an excellent alternative when no autogenous bone graft harvested during craniectomy is available.