Effectiveness of Continuous Hypertonic Saline in Acute Ischemic Infarcts: A Radiographic and Clinical Evaluation.

OBJECTIVE: The role of continuous hypertonic saline (HS) infusion in the management of malignant cerebral edema is controversial. We evaluated patients presenting with large anterior circulation territory infarcts and compared radiographic and clinical outcomes to evaluate the effects of continuous HS. METHODS: This was a retrospective review of patients with malignant ischemic strokes who were initially managed with continuous HS versus routine medical management. Radiographic parameters of cerebral edema and clinical parameters were collected at different time intervals after admission. Rates and timing of surgery, mortality, and complications were also collected. RESULTS: The study included 43 patients: 26 in group 1 (HS) and 17 in group 2 (no HS). Both cohorts had comparable baseline clinical and radiographic parameters. There was no difference between rates and timing of surgery, complications, and mortality. Mean midline shift was significantly greater in the HS group at interval 1 (12-36 hours, P = 0.003) and interval 2 (36-60 hours, P = 0.030), and mean change in midline shift from initial interval to interval 1 was significantly greater in the HS group (P = 0.019). CONCLUSIONS: Despite the widespread use of continuous HS in acute ischemic infarcts, only a limited number of studies have evaluated its efficacy, and virtually no studies have studied its effect on radiographic progression and rates of decompressive surgery. Results of this study indicate that there is no benefit of continuous HS. In fact, there may be worsening of cerebral edema with administration of continuous HS. In addition, there are no differences in prevention or delay of decompressive surgery or in overall mortality.

Management of giant prolactinoma causing craniocervical instability: illustrative case.

BACKGROUND: Giant prolactinomas (>4 cm) are a rare entity, constituting less than 1% of all pituitary tumors. Diagnosis can usually be achieved through endocrinological analysis, but biopsy may be considered when trying to differentiate between invasive nonfunctioning pituitary adenomas and primary clival tumors such as chordomas. OBSERVATIONS: The authors presented a rare case of a giant prolactinoma causing significant clival and occipital condyle erosion, which led to craniocervical instability. They provided a review of the multimodal management. Management involved medical therapy with dopamine agonists, and surgery was reserved for acute neural compression or dopamine agonist resistance, with the caveat that surgery was extremely unlikely to lead to normalization of serum prolactin in dopamine agonist-resistant tumors. LESSONS: Adjunctive surgical therapy may be necessary in cases of skull base erosion, particularly when erosion or pathological fractures involve the occipital condyles. Modern posterior occipital-cervical fusion techniques have high rates of arthrodesis and can lead to symptomatic improvement. This procedure should be considered early in the multimodal approach to giant prolactinomas because of the often dramatic response to medical therapy and potential for further craniocervical instability.

Ominous Occurrence of Spinal Intradural Primary Malignant Peripheral Nerve Sheath Tumor Four Decades following Radiation Therapy for Testicular Seminoma.

Primary intradural malignant peripheral nerve sheath tumor (MPNST) is an extremely rare diagnosis and is associated with an extremely poor prognosis. A 77-year-old man diagnosed with an intradural MPNST, more than 40 years after radiation for a testicular seminoma, is reported. Intradural MPNSTs of the spine outside the setting of neurofibromatosis is extremely rare and can masquerade as common benign nerve sheath tumors, on imaging. An older age at presentation with short duration of symptoms and prior regional radiation treatment encompassing the spine in the treatment field regardless of remoteness should alert the oncologists and neurosurgeons to the possible existence of this rare and aggressive tumor, as the management, and overall prognosis of this tumor is distinctly different compared to the usual intradural spinal tumors.

Stable Spondylolisthesis: Should Management Change Based on Presence of Facet Cysts?

STUDY DESIGN: This is a retrospective cohort review. OBJECTIVE: To determine whether a correlation exists between facet cysts and lumbar instability. SUMMARY OF BACKGROUND DATA: Lumbar facet cysts are common degenerative entities observed in patients with low-grade spondylolisthesis at a rate of 10%-50%. Surgical management with partial facetectomy with or without fusion remains controversial. METHODS: Review of 86 patients with lumbar degenerative spondylolisthesis is performed. Preoperative magnetic resonance imagings were reviewed for the presence of lumbar facet cysts and Facet Fluid Indices (FFI)-calculated as the ratio of facet fluid width to facet width. Instability was defined as a difference of >3 mm in vertebral displacement between flexion and extension radiographs. T tests and the Pearson correlation analyses were used to determine statistical significance. RESULTS: In total, 26 patients had unstable and 60 had stable spondylolisthesis. Facet cysts were present at an overall prevalence of 30.1%-in 10/26 patients in the unstable group and in 18/60 patients in the stable group (P>0.05). The average FFIs for the unstable and stable groups were 0.13 and 0.09, respectively (P>0.05). FFI in patients with facet cysts was significantly higher than those without (P<0.05). In addition, the group with facet cysts had a significantly higher proportion of patients with FF effusions >3 mm. CONCLUSIONS: Lack of correlation with instability hints that the presence of facet cysts may not indicate instability in lumbar degenerative spondylolisthesis. Therefore, presence of facet cysts in static magnetic resonance imaging revealing spondylolisthesis should not preclude the physician from performing dynamic films to evaluate for instability. Significantly higher FFI in patients with facet cysts reaffirms the degenerative pathophysiology involved in their formation. Although this is not an outcomes study, it does spark interest into whether patients with stable spondylolisthesis and concurrent facet cysts are suitable for partial facetectomy alone with fusion.

Comparing the Effectiveness of Sagittal Balance, Foraminal Stenosis, and Preoperative Cord Rotation in Predicting Postoperative C5 Palsy.

STUDY DESIGN: Retrospective cohort review. OBJECTIVE: To determine whether preoperative cord rotation is independently correlated with C5 palsy when analyzed alongside measures of sagittal balance and foraminal stenosis. SUMMARY OF BACKGROUND DATA: Postoperative C5 palsy is a well-documented complication of cervical procedures with a prevalence of 4%-8%. Recent studies have shown a correlation with preoperative spinal cord rotation. There have been few studies, however, that have examined the role of sagittal balance and foraminal stenosis in the development of C5 palsy. METHODS: A total of 77 patients who underwent cervical decompression-10 of whom developed C5 palsy-were reviewed. Sagittal balance was assessed using curvature angle and curvature index on radiographs and magnetic resonance image (MRI). Cord rotation was assessed on axial MRI. C4-C5 foraminal stenosis was assessed on sagittal MRI using area measurements and a grading scale. Demographics and information on surgical approach were gathered from chart review. Correlation with C5 palsy was performed by point-biserial, χ, and regression analyses. RESULTS: Point-biserial analysis indicated that only cord rotation showed significance (P<0.01). There was no statistical significance shown with surgical approach, sex, or age. In addition, changes in sagittal balance did not correlate with presence of C5 palsy. Logistic regression model yielded cord rotation as the only significant independent predictor of C5 palsy. For every degree of axial cord rotation, the likelihood ratio for suffering a C5 palsy was 3.93 (95% confidence interval, 2.01-8.66; P<0.05). CONCLUSIONS: This supports the independent capability of preoperative cord rotation to predict postoperative C5 palsy. Lack of correlation with measures of neuroforaminal stenosis potentially points to mechanisms other than direct compression as the etiology. In addition, the lack of correlation with postoperative changes in sagittal balance hints that measures of curvature angle and curvature index may not be appropriate to accurately predict this complication. LEVEL OF EVIDENCE: Level 3.