Stereotactic pallidotomy for treatment of Parkinson's disease.

There has been a resurgence of interest in surgical treatment of Parkinson's disease in the past five years due to the large number of patients who have medically intractable symptoms and because significant improvements in neuroimaging and stereotactic techniques have made surgical procedures safer and more accurate. Stereotactic pallidotomy procedures allow neurosurgeons to destroy a portion of the globus pallidus, and thereby, decrease patients' muscle rigidity from Parkinson's disease. These surgical procedures primarily involve magnetic resonance-guided stereotactic targeting and microelectrode recording techniques. To ensure successful patient outcomes, stereotactic pallidotomy procedures require special perioperative nursing interventions discussed in this article.

Interstitial chemotherapy with drug polymer implants for the treatment of recurrent gliomas.

Malignant gliomas have been difficult to treat with chemotherapy. The most effective agent, BCNU (carmustine), has considerable systemic toxicity and a short half-life in serum. To obviate these problems, a method has been developed for the local sustained release of chemotherapeutic agents by their incorporation into biodegradable polymers. Implantation of the drug-impregnated polymer at the tumor site allows prolonged local exposure with minimal systemic exposure. In this Phase I-II study, 21 patients with recurrent malignant glioma were treated with BCNU released interstitially by means of a polyanhydride biodegradable polymer implant. Up to eight polymer wafers were placed in the resection cavity intraoperatively, upon completion of tumor debulking. The polymer releases the therapeutic drug for approximately 3 weeks. Three increasing concentrations of BCNU were studied; the treatment was well tolerated at all three levels. There were no adverse reactions to the BCNU wafer treatment itself. The average survival period after reoperation was 65 weeks for the first dose group, 64 weeks for the second dose group, and 32 weeks for the highest dose group. The overall mean survival time was 48 weeks from reoperation and 94 weeks from the original operation. The overall median survival times were 46 weeks postimplant and 87 weeks from initial surgery. Eighteen (86%) of 21 patients lived more than 1 year from the time of their initial diagnosis and eight (38%) of 21 patients lived more than 1 year after intracranial implantation of the polymer. Frequent hematology, blood chemistry, and urinalysis tests did not reveal any systemic effect from this interstitial chemotherapy. Since the therapy is well tolerated and safe, a placebo-controlled clinical trial has been started. The trial will measure the effect of the second treatment dose on survival of patients with recurrent malignant glioma.

Reoperation for malignant astrocytoma.

We evaluated 15 consecutive patients with malignant astrocytomas who were reoperated for functional status and survival. Their Karnovsky Performance Status (KPS) was not changed by surgery. None suffered perioperative death, wound infection, or complications. Patients with glioblastoma maintained KPS unchanged for a mean of 13 weeks (median, 10 weeks); with anaplastic astrocytoma, mean, 37.2 weeks (median, 24 weeks). Life spans were approximately twice that of non-reoperated historical controls. Reoperation for patients with recurrent malignant astrocytoma should be seriously considered when a gross total re-resection can be the goal in a patient whose tumor is in an accessible brain region.

Revascularization for moyamoya disease: five-year follow-up.

We present a case of severe moyamoya disease in a 4-year-old child involving the anterior and posterior circulations. Encephaloduroarteriosynangiosis was performed and the child was followed for 5 years with serial angiography. Early clinical stabilization was attained and the child has normal or superior intellectual development despite her early fixed deficits. Follow-up angiography revealed the development of several large direct anastomotic channels.

Tethered cervical spinal cord. Case report.

A case of congenital tethered cervical spinal cord is presented in a young adult. Metrizamide computerized tomography was the most useful imaging technique for identifying the tethered spinal cord. Intraoperative somatosensory evoked potentials correlated well with clinical improvement following surgery.

Spontaneous reduction of a closed depressed skull fracture: a case report.

Presented is a single case of a 6-year-old child in whom a closed depressed skull fracture was found to be elevated spontaneously less than 2 days after the injury. There were no cosmetic or neurological sequelae at follow-up. This case demonstrates that these injuries do not always require operation and that they occasionally resolve spontaneously, even in school-age children.

MRI demonstration of clot in a small unruptured aneurysm causing stroke. Case report.

The case is reported of a 69-year-old woman with an 18-mm unruptured aneurysm of the right middle cerebral artery which caused a moderate stroke. Magnetic resonance imaging revealed a clot inside the aneurysm that was not visible on computerized tomography scans. The danger of embolism from the clot prompted clipping of the aneurysm.

Isolated ventricles following intraventricular hemorrhage.

Panventricular enlargement often follows intraventricular hemorrhage in the premature neonate. During a recent 12-month period, the authors identified five infants who required shunting because of symptomatic post-hemorrhagic hydrocephalus, which was progressive despite serial lumbar punctures and the use of indwelling subcutaneous ventricular reservoirs. In the first 6 months following placement of the initial shunt, four of the infants required an additional shunt for isolated ventricles. Two children had isolation of the lateral ventricles and required bilateral shunts. Two other children had isolation of the fourth ventricle from the lateral ventricular system and required posterior fossa shunts. All of the children were treated successfully using multiple shunts. In all cases, progressive dilation of the isolated ventricle was unaccompanied by the usual clinical signs of shunt malfunction. It appears that isolated ventricular systems are common following post-hemorrhagic hydrocephalus and these children must be followed closely with ultrasound and computerized tomography scanning.