Designing and Testing a Developmentally Appropriate Intervention for Children in a Psychiatric Residential Treatment Facility.

Preadolescent children in residential care have treatment needs that are different from adolescents. An intervention was created using developmental theory to inform decisions about the timing, objectives, strategies, and context best suited to preadolescents in an intensive residential treatment center. Aggressive behavior, seclusions, and restraints data for preadolescents during a 32-month period was used in the analysis. There was a significant decrease in aggressive behavior, seclusions, and restraints for preadolescents during the periods when the developmentally appropriate intervention was used versus the times when they received same intervention as the adolescents.

Sylvian Arteriovenous Malformation Resection and Associated Middle Cerebral Artery Aneurysm Clipping: Technical Nuances of Concurrent Surgical Treatment.

Approximately 10-30% of brain arteriovenous malformations (AVM) have associated arterial aneurysms (AAA), and the management of these lesions can be challenging. In this video technical note, we demonstrate the microsurgical treatment of an unruptured, Spetzler-Martin grade I AVM in the distal Sylvian fissure with two AAAs arising proximally from the inferior M2 trunk immediately distal to the middle cerebral artery (MCA) bifurcation. First, we resected the superficially located AVM to normalize the blood flow through the Sylvian vein. Next, we performed a Sylvian fissure dissection to access and clip the two MCA AAAs. We also discuss the technical nuances of tandem surgical intervention for AVMs with AAAs as it pertains to this case, particularly with respect to the order of lesion treatment, Sylvian fissure dissection, nidal resection, and aneurysm clipping.

Staged Multimodality Treatment of a Large Ruptured Fusiform Supraclinoid Internal Carotid Artery Aneurysm: Microsurgical Clip-assisted Endovascular Coiling.

In the contemporary era of aneurysm management, large fusiform aneurysms presenting with subarachnoid hemorrhage (SAH) remain particularly challenging lesions to successfully manage. We describe a staged, multimodal treatment strategy for a 71-year-old patient who presented with a large ruptured fusiform aneurysm of the supraclinoid internal carotid artery (ICA) and a fetal posterior communicating artery which originated from the inferomedial aspect of the aneurysm. In the first stage, we performed a partial microsurgical clip reconstruction of the fusiform aneurysm and secured its rupture site, which was identified intraoperatively. This left two residual saccular components of the aneurysm, which were targeted with endovascular coiling in the same hospitalization after the patient had convalesced from the SAH and was beyond the vasospasm window. We believe that this combined approach of clip-assisted coiling can be employed instead of endovascular flow diversion or microsurgical bypass for appropriately selected patients with ruptured fusiform ICA aneurysms.

Efficacy of endoscopic third ventriculostomy in fourth ventricular outlet obstruction.

OBJECTIVE: Fourth ventricular outlet obstruction (FVOO), an uncommon cause of obstructive hydrocephalus, is most commonly associated with prior intraventricular hemorrhage or intraventricular infection in children. There have been few reports of FVOO in an adult population. METHODS: Twenty-two patients with FVOO treated with endoscopic third ventriculostomy (ETV) were analyzed retrospectively. RESULTS: Of the 22 patients, 10 were younger than 2 years, 6 were between 2 and 18 years, and 6 were older than 18 years of age. Predisposing factors included tubercular meningitis (1 patient), ventriculitis (2 patients), and intraventricular hemorrhage (3 patients). Twelve patients (mostly >2 years of age) had no prior significant history. The third ventricular floor and the adhesions in the basal cisterns were individually graded (I-IV). An inflamed floor was encountered in 3 patients. ETV was successfully performed in 20 patients. Fourth ventricular exploration was carried out in 5 patients, with outlet membrane fenestration in 2 patients. The follow-up period was 1 to 8 years (mean, 4.2 years). The ETV failed in 7 patients, requiring shunt insertion. The overall success rate was 65%; 91% success was achieved in patients who were more than 2 years of age, whereas the procedure failed in all patients younger than 6 months of age. The cerebrospinal fluid yielded a positive bacterial culture (1 patient), antitubercular antibody (1 patient), anticysticercal antibody (1 patient), and cryptococcosis (1 patient). With a successful procedure, lateral ventricular size was reduced in all patients, whereas fourth ventricular size decreased in 12 patients. The extent of adhesions in the basal cisterns directly correlated with failure. None of the patients demonstrated isolated fourth ventricle on follow-up magnetic resonance imaging. In 4 of the 7 patients with failure, endoscopic exploration was performed, and a patent stoma was observed in all of these patients. CONCLUSION: ETV is a viable option for treatment of patients with FVOO. The high failure rate in infants younger than 6 months of age suggests that ventriculoperitoneal shunting is a favorable option in this age group, rather than ETV. Isolated fourth ventricle is uncommon after ETV in hydrocephalus attributable to FVOO.

Intraventricular occurrence of a melanocytoma.

Melanocytomas are rare tumors of the central nervous system that are believed to arise from leptomeningeal melanocytes. A young girl presented with a contrast-enhancing cystic mass in the temporal horn of the left lateral ventricle. Microsurgical resection of a black-colored vascular tumor supplied by the anterior choroidal artery was performed. Appropriate immunohistochemical staining and electron microscope evaluations were used to confirm the pathological diagnosis. The patient made an excellent recovery; follow-up imaging revealed no recurrent or residual tumor. This is the first documented primary occurrence of a melanocytoma in an intraventricular location. The intraventricular occurrence of this tumor suggests that melanocytes may migrate into the choroidal fissure and may infrequently undergo neoplastic proliferation in that location. This case contains implications for the differential diagnosis of intraventricular tumors.

Endocrine failure after traumatic brain injury in adults.

OBJECTIVE: To review histopathological and clinical data linking endocrine failure to traumatic brain injury (TBI) during acute neurosurgical treatment and rehabilitation. METHODS: A focused search of the Medline (PubMed) medical literature database and the authors' files were used to identify selected publications. RESULTS: Endocrine failure may produce clinically important consequences during acute and convalescent care after TBI, and may be caused by direct injury to the hypothalamic- pituitary axis (HPA), neuroendocrinological effects from catecholamines and cytokines, or from systemic infection/inflammation that produces primary gland failure. Autopsy evidence of hemorrhage or ischemia in the HPA is common soon after TBI. The estimated incidence of acute hormone reduction is adrenal 15%, thyroid 5 - 15%, growth hormone 18%, vasopressin 3 - 37%, and gonadal (25 - 80%). Hyperprolactinemia occurs in more than 50% of patients. Inappropriate secretion of antidiuretic hormone (SIADH) and the euthyroid sick syndrome are common. Acute adrenal failure, central hypothyroidism, SIADH, and diabetes insipidus (DI) may cause poor neurological outcomes including death, hypo/hypernatremia, hypotension, and increased vasoactive drug requirements. Treatment of those conditions is warranted. Delayed diagnosis of hypopituitarism is often mistaken for symptoms of residual head injury. Some chronic hormone deficiency occurs in 30 - 40% of selected patients after TBI, more than one deficiency in 10 - 15%, growth hormone in 15 - 20%, gonadal hormones in 15%, and hypothyroidism in 10 - 30%. Chronic adrenal failure and DI are reported over a wide incidence. Prolactin is elevated in 30%. All clinical symptoms respond favorably to replacement therapy. CONCLUSIONS: Severe TBI associated with basilar skull fracture, hypothalamic edema, prolonged unresponsiveness, hyponatremia, and/or hypotension is associated with a higher occurrence of endocrinopathy. Greater awareness of this possible complication of TBI and appropriate testing are encouraged.

Cerebral mycotic aneurysms treated with a neuroform stent: technical case report.

OBJECTIVE AND IMPORTANCE: We describe the first documented endovascular treatment of proximal intracranial mycotic aneurysms by a self-expanding, flexible, dedicated, intracranial Neuroform stent. Treatment with this stent rapidly obliterated the aneurysms, eliminated the need for additional coiling, and maintained the patency of the parent arteries. CLINICAL PRESENTATION: A 47-year-old male patient with infective endocarditis presented with ischemic stroke and minimal subarachnoid hemorrhage. Cerebral angiography demonstrated a fusiform aneurysm of the supraclinoid segment of the left internal carotid artery and horizontal segment of the left middle cerebral artery, with superimposing side-wall focal aneurysms. Despite antibiotic therapy, the focal aneurysms progressively enlarged, as demonstrated on a subsequent cerebral angiogram at Day 11. INTERVENTION: A 4-mm x 2-cm Neuroform stent was deployed along the fusiform aneurysm of the left supraclinoid internal carotid artery and the horizontal middle cerebral artery M-1 segment encompassing the focal side-wall aneurysms with preserved patency of the parent arterial segments. CONCLUSION: Endovascular stent placement can be an effective treatment for proximal intracranial mycotic aneurysms that fail to respond to medical therapy.

Minimal model to document psychometric change after standard anterior temporal lobectomy for intractable seizure disorder.

Neuropsychological assessment of persons with epilepsy is recommended whenever neurosurgery is considered as an alternative therapy for seizure disorders refractory to ordinary medical management. Although psychological assessment is common in centers specialized in the care of epilepsy patients, standardized protocols are not common. This study addresses the question of the optimal minimal test battery necessary to differentiate groups of right-handed patients with refractory, complex partial seizure disorder who receive either right or left anterior temporal lobectomy or no surgery. No variable differentiated the groups before surgery. Only Logical Memory-Immediate of the Wechsler Memory Scale differentiated the groups following surgery. This finding is consistent with the literature.

Late-developing cerebral arteropathy after pyogenic meningitis.

BACKGROUND: Although vasculopathy is a recognized complication during acute meningitis, to our knowledge, no previous reports have been published of this phenomenon developing months after successful treatment. OBJECTIVE: To report a unique case of a late-developing vasculopathy after pyogenic meningitis in an adult. REPORT OF A CASE: A 51-year-old woman was seen with severe headache 2 months after treatment of Haemophilus influenzae type C meningitis. Initial arteriography showed no abnormality; a second arteriogram showed progressive multifocal intracranial stenosis affecting mainly the internal carotid arteries. Findings from pathologic examination disclosed diffuse collagenosis consistent with chronic vascular injury from meningitis. The arterial lesions stabilized, and the patient remained asymptomatic. CONCLUSION: Progressive intracranial arterial stenosis can evolve months after meningitis and should be added to the list of recognized vascular complications.

Reversal of attenuation of cerebrovascular reactivity to hypercapnia by a nitric oxide donor after controlled cortical impact in a rat model of traumatic brain injury.

OBJECT: Traumatic brain injury (TBI) attenuates the cerebral vasodilation to hypercapnia. Cortical spreading depression (CSD) also transiently reduces hypercapnic vasodilation. The authors sought to determine whether the CSD elicited by a controlled cortical impact (CCI) injury masks the true effect of TBI on hypercapnic vasodilation, and whether a nitric oxide (NO) donor can reverse the attenuation of hypercapnic vasodilation following CCI. METHODS: Anesthetized rats underwent moderate CCI. Cerebral blood flow was monitored with laser Doppler flowmetry and the response to hypercapnia was determined for injured and sham-injured animals. The effect of the NO donor, S-nitroso-N-acetylpenicillamine (SNAP), on this response was also assessed. At an uninjured cortical site ipsilateral to the CCI, a single wave of CSD was recorded and the CO2 response at this location was significantly attenuated for up to 30 minutes (seven rats, p < 0.05). At the injured cortex, hypercapnic vasodilation continued to be attenuated for 7 hours. The cerebral vasodilation to CO2 was 37 +/- 5% in injured rats (six) compared with 84 +/- 10% in the sham-injured group (five rats, p < 0.05). After 30 minutes of topical superfusion with SNAP, hypercapnic vasodilation was restored to 74 +/- 7% (nine rats, p > 0.1 compared with that in the sham-injured group). In contrast, papaverine, an NO-independent vasodilator, failed to reverse the attenuation of the CO2 response to CCI. CONCLUSIONS: The authors conclude that CSD elicited by CCI can mask the true effect of TBI on hypercapnic vasodilation for at least 30 minutes. Exogenous NO, but not papaverine, can reverse the attenuation of cerebrovascular reactivity to CO2 caused by TBI. This result supports the hypothesis that NO production is reduced after TBI and that the NO donor has a potential beneficial role in the clinical management of head injury.

Fractionated stereotactic intensity-modulated radiotherapy (FS-IMRT) for small acoustic neuromas.

Eight patients with acoustic neuromas were treated using a novel method developed at our institution for delivering fractionated stereotactic intensity-modulated radiotherapy (FS-IMRT). We present treatment parameters, dosimetry analysis, and preliminary clinical outcome. The method incorporates high-precision invasive fixation, obliquely-oriented tomotherapy arcs, and reduced dimension pencil beams. The delivered dose distributions for the 8 patients treated from April 1999 to May 2001 were assessed for dose conformality, homogeneity, and doses to organs at risk. Total doses prescribed were 54 Gy in daily doses of 1.8 Gy. Results show that the median planning target volume (gross tumor volume plus a safety margin of 2 mm) was 2.48 cm3 (1.64 to 16.86 cm3) and that the median conformality and homogeneity indices were 1.69 (1.56 to 2.16) and 1.12 (1.09 to 1.19), respectively. The respective average mean and maximum doses to the brain stem were 12.67 Gy and 53.86 Gy. The treatment parameters for the novel FS-IMRT method developed here document excellent dose conformality and normal tissue sparing. Preliminary short-term follow-up (mean 17, median 18.5 months) revealed a 100% local control and hearing preservation rate. No new persistent impairment of facial and trigeminal nerve was observed. Our current follow-up experience indicates a reasonable potential for achieving outcomes comparable to established stereotactic radiotherapy techniques.