Focal brainstem gliomas. Advances in intra-operative management.

Improved neuronavigation guidance as well as intraoperative imaging and neurophysiologic monitoring technologies have enhanced the ability of neurosurgeons to resect focal brainstem gliomas. In contrast, diffuse brainstem gliomas are considered to be inoperable lesions. This article is a continuation of an article that discussed brainstem glioma diagnostics, imaging, and classification. Here, we address open surgical treatment of and approaches to focal, dorsally exophytic, and cervicomedullary brainstem gliomas. Intraoperative neuronavigation, intraoperative neurophysiologic monitoring, as well as intraoperative imaging are discussed as adjunctive measures to help render these procedures safer, more acute, and closer to achieving surgical goals.

Length of MRI signal may predict outcome in advanced cervical spondylotic myelopathy.

OBJECTIVE: To study clinical and radiological factors that may correlate with independent walking (IW) following advanced cervical spondylotic myelopathy (CSM) surgery. METHODS: A retrospective case series including all advanced CSM patients (Nurick 4 and 5) who underwent surgery from 2003-2010 in the Division of Neurosurgery, Department of Surgery, College of Medicine, King Saud University and King Khalid University Hospital, Riyadh, Saudi Arabia. Only patients with 6 months or more follow-up were included. A neuroradiologist who was blinded to the clinical data reviewed all MRI studies. RESULTS: Forty-three patients were included (83% males, mean follow-up 29 months). A better preoperative neurological status was a positive predictor of IW after surgery (85.7% Nurick 4 versus 36.4% Nurick 5, p=0.001). Independent walking was less likely in patients with the following MRI features: longer T2-weighted image (T2WI) signal changes (p=0.001), well-circumscribed T2WI signal changes (p=0.028), T1WI hypointensity (p=0.001), and narrow spinal canal diameter (p=0.048). Multivariate regression revealed that both an increased T2WI signal change length and T1WI hypointensity were independent predictors. The risk of dependent walking increased by 1.35 times as the T2WI signal intensity length increased by one mm, and by 14-times with T1WI hypointensity. CONCLUSION: Regaining IW after surgery in patients with advanced CSM was less likely for cases showing MRI features of longer T2WI signal changes and T1WI hypointensity. Better baseline walking, less defined T2WI signal change, and a wider spinal canal were good prognostic factors.

Pediatric brainstem tumors. Classifications, investigations, and growth patterns.

Brainstem gliomas occur in 10-20% of brain tumors in pediatrics. Over the past 3 decades, the treatment of brainstem gliomas has significantly progressed as a result of the gradual advancements in microsurgical techniques, sophisticated imaging technology and, most importantly, the availability of MRI. In this article, we review the current literature on brainstem gliomas and cover diagnosis, imaging, classification, and management. Surgical approaches and intraoperative modalities to tackle operable cases of brainstem gliomas will be discussed in a follow up article.

Prevalence of symptoms and risk of sleep apnea in patients with ruptured cerebral aneurysm.

OBJECTIVE: To determine the prevalence of symptoms and risk of obstructive sleep apnea (OSA) among patients with ruptured cerebral aneurysms. METHODS: In this case-control study, a validated Arabic version of the Berlin Questionnaire (BQ) was administered to patients admitted to King Fahd Medical City, Riyadh, Saudi Arabia with cerebral aneurysms between January 2006 and July 2011 (n=53). The same questionnaire was administered to a control group comprised of patients attending primary health care clinics who were matched for age, body mass index (BMI), and gender (n=212). RESULTS: The mean age of patients with ruptured cerebral aneurysms was 50.7 +/- 15.2 years, and the mean BMI was 27.9 +/- 4.8 kg/m2. In this group, 75.5% complained of snoring compared with 46.7% of the controls (p=0.000). Hypertension was present in 67.9% of cases compared with 30.2% of the controls (p=0.000). Based on the BQ scores, 60.4% of the cases were considered to be at high risk for OSA compared with 31.6% of the controls (p=0.000). CONCLUSION: The prevalence of OSA symptoms among patients with ruptured cerebral aneurysms is very high. Almost 60% of patients with ruptured cerebral aneurysms are at risk for OSA.