Prophylaxis to avert exacerbation/relapse of multiple sclerosis in affected patients undergoing surgery. Surgical observations and recommendations.

To provide the neurological and neurosurgical communities with case evidence of postoperative multiple sclerosis (MS) relapse, literature review to support operative stress-induced relapse and recommendations for perioperative prophylaxis to prevent relapse in patients undergoing surgery. Two case studies are presented with recommendations based on an extensive review of the medical literature and personal experience to support perioperative prophylactic suggestions. Both patients fully recovered to preoperative functional status after treatment. We now routinely implement perioperative prophylaxis to MS patients undergoing surgery at our institution with no complications to date. Perioperative prophylaxis in patients with MS undergoing surgery can prevent relapse. It is of utmost importance that the surgical community realizes that prophylactic treatment is available and should be utilized during elective and emergent surgical situations.

Chiasmal compression from fat packing after transsphenoidal resection of intrasellar tumor in two patients.

After transsphenoidal resection of a pituitary (or other) tumor, the remaining intrasellar cavity, and sphenoid sinus are usually packed with exogenous fat or muscle to prevent cerebrospinal leak and prolapse of the optic chiasm into an empty sella. We treated two patients in whom chiasmal compression occurred postoperatively because of packing of fat. In one patient, the expected visual improvement in the postoperative period was suboptimal. The subsequent removal of fat resulted in total visual recovery. In the other patient, chiasmal compression persisted from intrasellar fat and residual tumor. Iatrogenic compression of the optic nerves or chiasm should be considered in all patients in whom visual recovery is incomplete.

The course of lymphocytic hypophysitis.

A 27-year-old woman presented to our institution in her seventh month of pregnancy with complaints of headache and visual field disturbance. Workup revealed bitemporal hemianopia, a markedly enlarged pituitary gland on computed tomography scan, and biochemical evidence of partial hypopituitarism. At surgery, a biopsy specimen of the pituitary gland was taken revealing lymphocytic hypophysitis. The patient was treated with steroids and replacement doses of thyroid hormone. Visual fields improved postoperatively. A repeat computed tomography scan obtained 2 months after an uneventful pregnancy showed that her pituitary had regained normal size and contour. Over the next 9 months she had gradual recovery of all pituitary function. This case allowed us to follow and document the course of lymphocytic hypophysitis from its presentation as a macroadenoma with partial hypopituitarism to full recovery of both size and hormonal function of the pituitary. Lymphocytic hypophysitis should be considered in the differential diagnosis of a pituitary mass or pituitary dysfunction presenting in pregnancy. In patients with suspected lymphocytic hypophysitis and a pituitary mass, a trial of steroids may be therapeutic.

Progressive coma after the transsphenoidal decompression of a pituitary adenoma with marked suprasellar extension: report of two cases.

Two cases of neurological deterioration and coma after the transsphenoidal decompression of a pituitary adenoma with marked suprasellar extension and invasion of the 3rd ventricle are presented. Emergency ventricular shunting led to prompt neurological improvement, which, supplemented by radiation therapy, allowed long-term amelioration of symptoms. Three possible explanations for this complication are offered: 1) traction of the attached 3rd ventricle into the decompression site, causing increased obstructive hydrocephalus, 2) vasopressin release by surgical manipulation of the pituitary stalk and circumventricular organs causing cerebral edema, and 3) edema in the residual tumor secondary to surgical manipulation causing further hydrocephalus. Subsequent patients with similar clinical and imaging criteria will have a planned perioperative ventricular shunting procedure performed.

Intradural disc herniations in the cervical, thoracic, and lumbar spine: report of three cases and review of the literature.

The clinical, neuroradiological, and surgical management of three cases of intradural disc herniations--one each in the cervical, thoracic, and lumbar regions--are presented. Intradural disc herniations comprise only 0.27% of all herniated discs. Three percent occur in the cervical, 5% in the thoracic, and 92% in the lumbar spinal canal. Those with cervical or thoracic lesions frequently exhibit profound myelopathy, whereas those with lumbar lesions demonstrate radicular or cauda equina syndromes. Although varying combinations of the MRI, non-contrast CT, myelogram, and myelo-CT scans may at times fail to accurately establish the diagnosis of an intradural disc herniation prior to surgery, the index of suspicion raised by the lack of clinical correlation with surgical findings justifies an intradural exploration.

Primitive neuroectodermal tumor presenting as a delayed sequela to cranial irradiation and intrathecal methotrexate.

A patient developed a primitive neuroectodermal tumor (PNET) many years after therapeutic cerebral radiation and methotrexate treatment for leukemia. The differential radiologic and histologic diagnoses, as well as the possible co-oncogenic effects of radiation and methotrexate, are evaluated.

Extensive surgical excision of large hemispheric "malignant" astrocytoma in a 6-week-old infant.

A massive hemispheric "high"-grade astrocytoma, diagnosed in a 6-week-old infant, was totally excised by means of two craniotomies. The child is still alive and well with minimal neurological dysfunction 1.5 years after operation. This case report illustrates the benefit of aggressive surgical excision (without radiation or chemotherapy) of massive malignant neonatal astrocytomas. While surgical deficits may be minimized by the plasticity of the developing nervous system, extensive excision may yield occasional long-term palliation.

Paraganglioma of the cauda equina. A histologic, immunohistochemical, and ultrastructural study and review of the literature.

We report a case of paraganglioma of the cauda equina and filum terminale. Diagnosis was established by the histologic organoid pattern, immunohistochemical staining for neuron-specific enolase and ultrastructural dense-core neurosecretory granules. A survey of the literature yielded 16 previously reported cases, five of which were described in 1983. This suggests that heightened awareness of this entity will result in a corresponding increase in the reported incidence.

Spinal epidural venous angioma causing foraminal enlargement and erosion of vertebral body. Case report.

A case history of a segmental epidural venous angioma is presented. Findings included foraminal enlargement and vertebral body erosion. Routine computerized tomography with contrast enhancement should be helpful in diagnosis of vascular anomalies in patients with radicular symptoms.

Obliterative arachnoiditis complicating lumbar spinal stenosis.

The authors report five patients with spinal stenosis who had a total myelographic block at the level of the obliterated subarachnoid space. Arachnoiditis had not been considered as a primary diagnosis until laminectomy revealed a non-pulsating, thickened dural sac that conformed to the internal configuration of the involved spinal canal. Two patients had stenosis complicated by spondyloarthrosis over multiple lumbar levels, one had a previous spinal fusion, another had degenerative spondylolisthesis, and the fifth had a large midline extruded disc at L2-3 that completely blocked the spinal canal. The dura was opened in two patients, confirming the lesion. Despite obliteration of the subarachnoid space, significant relief for approximately 1 year followed decompressive laminectomy, foraminotomy, and discectomy, with disappearance of neurogenic claudication in three patients. Postoperative erect films showed no caudad passage of contrast. While further observations are required, an awareness of this complication of spinal stenosis is important in the diagnosis and management of such patients and in evaluating their ultimate prognosis.

Microsurgical treatment of internal carotid artery aneurysms.

Seventy consecutive cases of internal carotid artery aneurysm were operated on utilizing the surgical microscope. There were three deaths (4.3% mortality), one of which occurred in a deeply comatose apneic patient. Fifty-nine patients (84%) had excellent results. Four (6%) had postoperative morbidity directly related to their operation; three of them were operated on within 2 weeks after subarachnoid hemmorrhage and had neurological deficits attributed to cerebrovascular spasm. The low morbidity and mortality rates are partially related to patient selection but also significantly influenced by improved surgical techniques made possible by the microscope and microsurgical instrumentation. It is the authors' opinion that microsurgery should be standard procedure for craniotomy for intracranial aneurysm. It is suggested that future reported series of aneurysm therapy, regardless of the method of treatment employed, should be compared with the anticipated natural history.

Transsphenoidal chiasmapexy for correction of posthypophysectomy traction syndrome of optic chiasm. Case report.

Postoperative improvement occurred as a result of transsphenoidal chiasmapexy in a patient with posthypophysectomy visual loss. Traction injury of the optic chiasm may have been caused by a deficient diaphragma sellae and inadequate packing and repair of the sella floor. A cartilaginous seal is recommended.

Complete embolization of artery of Adamkiewicz to obliterate an intramedullary arteriovenous aneurysm. Case report.

A case history of an intramedullary arteriovenous aneurysm of the thoracolumbar junction is presented, and an unusual 14-year follow-up after the original sub-arachnoid bleeding episode is detailed. Embolization of anterior and mixed angiomas involving the artery of Adamkiewicz may be feasible when the artery is large and shunting is present.