Improvement of Hemichorea Following Surgical Resection of a Putaminal Cavernous Angioma: Case Report and Review of Literature.

BACKGROUND: Hemichorea may point to a structural lesion in the contralateral basal ganglia with a large list of possible causes. Cavernous angioma may be rarely a possible cause for acute appearance of this movement disorder. CASE DESCRIPTION: We present a rare case of a 32-year-old female patient with hemichorea caused by a cavernoma (or cavernous angioma) in the contralateral insula and putamen with complete improvement of symptoms with surgical resection of the lesion. CONCLUSIONS: We believe that surgical resection of basal ganglia cavernomas may be feasible with minor risks and resolution of clinical symptoms in the immediate postoperative period.

Evaluating cerebellar dentatotomy for the treatment of spasticity with or without dystonia.

Spasticity represents a common and very often incapacitating neurologic condition, for which a limited number of treatment options are available. Stereotactic ablation of the dentate cerebellar nuclei (dentatotomy) was widely used in the past with variable results. In the present study, we reviewed 12 consecutive cases operated on at the Midland Centre for Neurosurgery and Neurology at Birmingham University (Smetwick, UK) in the 1980s. The following clinical aspects were analyzed: severity of spasticity, occurrence of abnormal movements (dystonia/athetosis), language fluency, gait, and overall clinical condition. Follow-up ranged from 0.5 to 94 (mean: 31.6) months. Immediate improvement was noted in 10 patients, and five of them had sustained this improvement at the time of the last assessment. A more pronounced improvement was observed for gait, relative to speech and abnormal movements. No significant morbidity related to the procedure was observed. We conclude that dentatotomy is a safe procedure that should still be considered in specific cases. Here, we review the cases reported in the literature, and present a mechanistic hypothesis about how dentatotomy influences motor tonus, in light of the current knowledge about cerebellar physiology. We believe that this issue is critical for the development of alternative surgical approaches targeting the cerebellum, such as chronic electric stimulation.

[Evaluation of the functional results in the treatment of pelvic limbs with multiple level surgery in spastic ICP patients]. / Evaluación de resultados funcionales en el tratamiento de miembros pélvicos con cirugía multinivel en pacientes espásticos con parálisis cerebral infantil.

UNLABELLED: The purpose of this study is to assess the effects of multiple level surgery of the pelvic limbs in patients with spastic infantile cerebral palsy seen at the National Rehabilitation Institute and show that their clinical improvement is comparable to the reports in the national and international literature. MATERIAL AND METHODS: This is a longitudinal, prospective, descriptive, self-controlled, before-and-after clinical trial that included patients with spastic infantile cerebral palsy who underwent multiple-level single-stage surgery from January 2007 to August 2008. The inclusion criteria were as follows: both genders, ages 4 to 16 years, with a complete clinical file, with preoperative and 8-12 month postoperative rehabilitation. Elimination criterion: any event not related with multiple-level surgery. Exclusion criterion: any surgeries prior to admission. A descriptive statistical analysis was used, together with the Student t-test and the chi-square test. RESULTS: 81 patients with a mean age of 7 +/- 3.2, an age range of 4-16 years; 60.5% males and 39.5% females. The subtypes of spastic infantile cerebral palsy were as follows: biparesis 64.2%, quadriparesis 22.2%, hemiparesis 8.6%, double hemiparesis 4.9%. The clinical-surgical classification (14) changed as a result of improvement and according to the number of surgical procedures: 6 patients (7.4%) had significant improvement (p = 0.13) with one procedure; 44 patients (54.3%) had significant improvement (p = 0.002) with two procedures; 28 patients (34.6%) had significant improvement (p = 0.04) with three procedures, and 3 patients (3.7%) had significant improvement (p = 0.19) with four procedures. On the other hand, when the number of surgical procedures was related with the diagnostic subtype of spastic infantile cerebral palsy, in those undergoing one procedure the clinical-surgical classification did not change in the cases of biparesis (p = 0.26), hemiparesis (p = 0.18), and double hemiparesis (p = 0.50). In those undergoing two surgical procedures the significant changes occurred for the cases of biparesis (p = 0.20), quadriparesis (p = 0.007), and double hemiparesis (p = 0.16). In those undergoing four procedures no changes occurred in the cases of biparesis (p = 0.26) and hemiparesis (p = 0.50). DISCUSSION: An improvement in the clinical-surgical classification was observed (p = 0.0001) based on the results of Gazi Zorer, as well as a significant improvement (p < 0.001) and an improvement reported by the gait analysis by the following authors: Ugur Sayli, Gouth, MA Khan.

Transfer of supinator motor branches to the posterior interosseous nerve in C7-T1 brachial plexus palsy.

OBJECT: In C7-T1 palsies of the brachial plexus, shoulder and elbow function are preserved, but finger motion is absent. Finger flexion has been reconstructed by tendon or nerve transfers. Finger extension has been restored ineffectively by attaching the extensor tendons to the distal aspect of the dorsal radius (termed tenodesis) or by tendon transfers. In these palsies, supinator muscle function is preserved, because innervation stems from the C-6 root. The feasibility of transferring supinator branches to the posterior interosseous nerve has been documented in a previous anatomical study. In this paper, the authors report the clinical results of supinator motor nerve transfer to the posterior interosseous nerve in 4 patients with a C7-T1 root lesion. METHODS: Four adult patients with C7-T1 root lesions underwent surgery between 5 and 7 months postinjury. The patients had preserved motion of the shoulder, elbow, and wrist, but they had complete palsy of finger motion. They underwent finger flexion reconstruction via transfer of the brachialis muscle, and finger and thumb extension were restored by transferring the supinator motor branches to the posterior interosseous nerve. This nerve transfer was performed through an incision over the proximal third of the radius. Dissection was carried out between the extensor carpi radialis brevis and the extensor digitorum communis. The patients were followed up as per regular protocol and underwent a final evaluation 12 months after surgery. To document the extent of recovery, the authors assessed the degree of active metacarpophalangeal joint extension of the long fingers. The thumb span was evaluated by measuring the distance between the thumb pulp and the lateral aspect of the index finger. RESULTS: Surgery to transfer the supinator motor branches to the posterior interosseous nerve was straightforward. Twelve months after surgery, all patients were capable of opening their hand and could fully extend their metacarpophalangeal joints. The distance of thumb abduction improved from 0 to 5 cm from the lateral aspect of the index finger. CONCLUSIONS: Transferring supinator motor nerves directly to the posterior interosseous nerve is effective in at least partially restoring thumb and finger extension in patients with lower-type injuries of the brachial plexus.

Results of c5 root grafting to the musculocutaneous nerve using pedicled, vascularized ulnar nerve grafts.

PURPOSE: Vascularized nerve grafts are indicated for the repair of large nerve defects. In brachial plexus injuries, the poor prognosis for functional hand reconstruction when the lower roots are avulsed makes the ulnar nerve a potential donor for vascularized nerve grafts. We report on the results we obtained with reconstruction of elbow flexion using long pedicled ulnar nerve grafts that connected the C5 root to the musculocutaneous nerve. METHODS: We prospectively studied 8 young adults with complete brachial plexus palsy with avulsion of the lower roots, who had surgical repair an average of 4.6 months after trauma. Pedicled ulnar nerve grafts, averaging 30 cm long, connected the C5 root to the musculocutaneous nerve. In order to rescue misdirected axons that could have regenerated into the cutaneous branch of the musculocutaneous nerve, we transferred this branch to the motor branch of the extensor carpi radialis brevis muscle. Outcomes for all 8 patients were assessed an average of 26.7 months after surgery, focusing on recovery of muscle strength, categorized using the Medical Research Council scale. RESULTS: None of the patients recovered elbow flexion or wrist extension greater than M2. CONCLUSIONS: In brachial plexus injuries, reconstruction of elbow flexion using a long, pedicled, vascularized nerve graft produces unsatisfactory results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Outcome of fully awake craniotomy for lesions near the eloquent cortex: analysis of a prospective surgical series of 79 supratentorial primary brain tumors with long follow-up.

BACKGROUND: Despite possible advantages, few surgical series report specifically on awake craniotomy for intrinsic brain tumors in eloquent brain areas. OBJECTIVES: Primary: To evaluate the safety and efficacy of fully awake craniotomy (FAC) for the resection of primary supratentorial brain tumors (PSBT) near or in eloquent brain areas (EBA) in a developing country. Secondary: To evaluate the impact of previous surgical history and different treatment modalities on outcome. PATIENTS AND METHODS: From 1998 to 2007, 79 consecutive FACs for resection PSBT near or in EBA, performed by a single surgeon, were prospectively followed. Two groups were defined based on time period and surgical team: group A operated on from March 1998 to July 2004 without a multidisciplinary team and group B operated on from August 2004 to October 2007 in a multidisciplinary setting. For both time periods, two groups were defined: group I had no previous history of craniotomy, while group II had undergone a previous craniotomy for a PSBT. Forty-six patients were operated on in group A, 46 in group B, 49 in group I and 30 in group II. Psychological assessment and selection were obligatory. The preferred anesthetic procedure was an intravenous high-dose opioid infusion (Fentanil 50 microg, bolus infusion until a minimum dose of 10 microg/kg). Generous scalp and periosteous infiltrations were performed. Functional cortical mapping was performed in every case. Continuous somato-sensory evoked potentials (SSEPs) and phase reversal localization were available in 48 cases. Standard microsurgical techniques were performed and monitored by continuous clinical evaluation. RESULTS: Clinical data showed differences in time since clinical onset (p < 0.001), slowness of thought (p = 0.02) and memory deficits (p < 0.001) between study periods and also time since recent seizure onset for groups I and II (p = 0.001). Mean tumor volume was 51.2 +/- 48.7 cm3 and was not different among the four groups. The mean extent of tumor reduction was 90.0 +/- 12.7% and was similar for the whole series. A trend toward a larger incidence of glioblastoma multiforme occurred in group B (p = 0.05) and I (p = 0.04). Recovery of previous motor deficits was observed in 75.0% of patients, while motor worsening in 8.9% of cases. Recovery of semantic language deficits, control of refractory seizures and motor worsening were statistically more frequent in group B (p = 0.01). Satisfaction with the procedure was reported by 89.9% of patients, which was similar for all groups. Clinical complications were minimal, and surgical mortality was 1.3%. CONCLUSIONS: These data suggest that FAC is safe and effective for the resection of PSBT in EBA as the main technique, and in a multidisciplinary context is associated with greater clinical and physiological monitoring. The previous history of craniotomy for PSBT did not seem to influence the outcome.

Skeletal dysplasia and myelopathy in congenital disorder of glycosylation type IA.

We report on a boy with a congenital disorder of glycosylation (CDG) Ia and a severe narrowing of the spinal canal caused by atlantoaxial subluxation with anterior displacement of C1. C1-laminectomy improved the progressive paresis. Progressive paresis caused by spinal cord compression is a hitherto unrecognized complication in patients with CDG-Ia.

Reconstrucción de mano en pacientes cuadripléjicos / Hand reconstruction in quadriplegic patients

Se presenta un informe del protocolo de reconstrucción de mano en pacientes cuadripléjicos. Hasta el momento se han incluido en el estudio cinco pacientes, cuatro hombres y una mujer, tratados quirúrgicamente con base en lo expuesto en publicaciones sobre el tema, con modificaciones en la técnica quirúrgica. Los procedimientos consistieron en artrodesis de muñeca y transposiciones tendinosas. Los pacientes fueron operados según los elementos funcionales útiles a nivel de antebrazo, tomando en consideración la clasificación de Zancolli. Los resultados obtenidos hasta el momento son alentadores, con periódos que van de siete a 18 meses, aunque no se pueden considerar definitivos, dado el corto tiempo y el número reducido de pacientes. Las artrodesis han logrado una buena consolidación y la función de las transposiciones tendinosas es adecuada. Los pacientes refieren gran mejoría en las funciones básicas de la mano, mayor autosuficiencia y, como efecto agregado, un cambio favorable en su estado animico

Planejamento cirúrgico para as paresias unilaterais do oblíquo superior / Surgical planning for the unilateral superior oblique palsy

É apresentado uma experiência no planejamento cirúrgico para a paresia unilateral do oblíquo superior. Divide ele o quadro clínico causado pela paresia desse músculo em 6 classes e propöe um esquema cirúrgico específico para cada uma delas, exemplificando com casos reais de pacientes operados pelo autor, com as medidas pré e pós-operatórias