Conception in an infertile patient following obliteration of a huge anterior sacral meningocele: case report.

INTRODUCTION: We present the case of a 35-year-old woman with a large anterior sacral meningocele who had been unable to conceive. RESULT AND DISCUSSION: Following neurosurgical consultation, she underwent repair of her meningocele which resulted in complete resolution of her meningocele and 1 year later, she delivered her first child. CONCLUSION: This case demonstrates that following surgical treatment, female patients with anterior sacral meningoceles may be able to conceive and bear children.

Phase Ib trial of mutant herpes simplex virus G207 inoculated pre-and post-tumor resection for recurrent GBM.

We have previously demonstrated safety of G207, a doubly mutated (deletion of both gamma(1)34.5 loci, insertional inactivation of U(L)39) herpes simplex virus (HSV) for patients stereotactically inoculated in enhancing portions of recurrent malignant gliomas. We have now determined safety of two inoculations of G207, before and after tumor resection. Inclusion criteria were histologically proven recurrent malignant glioma, Karnofsky score >or=70, and ability to resect the tumor without ventricular system breach. Patients received two doses of G207 totaling 1.15 x 10(9) plaque-forming units with 13% of this total injected via a catheter placed stereotactically in the tumor. Two or five days later, tumor was resected en bloc with catheter in place. The balance of G207 dose was injected into brain surrounding the resection cavity. Six patients with recurrent glioblastoma multiforme were enrolled. Two days after the second G207 inoculation, one patient experienced transient fever, delirium, and hemiparesis, which entirely resolved on high-dose dexamethasone. No patient developed HSV encephalitis or required treatment with acyclovir. Radiographic and neuropathologic evidence suggestive of antitumor activity is reported. Evidence of viral replication was demonstrated. G207 appears safe for multiple dose delivery, including direct inoculation into the brain surrounding tumor resection cavity.

Spinal accessory nerve meningioma in a paediatric patient: case report.

Accessory nerve meningiomas are exceedingly rare. We present a case of a nine-year-old patient with neurofibromatosis type 2 who had radiologic evidence of spinal cord compression from an upper cervical/foramen magnum lesion. He was asymptomatic from this lesion, but it progressed in size. The tumor was resected and histologic investigation revealed frequent tight whorls and psammoma bodies consistent with meningioma. To the authors' knowledge, this is the first reported spinal accessory nerve meningioma in a pediatric patient.

The lateral atlantooccipital ligament.

INTRODUCTION: Stability of the atlantooccipital joint is of vital importance. The ligaments of this region, for the most part, have been thoroughly investigated, except for the lateral atlantooccipital ligament (LAO), which is not described in most modern texts. MATERIALS AND METHODS: The authors examined 20 adult cadaveric specimens to observe the morphology of the LAO. RESULTS: All specimens were found to have an LAO, bilaterally, immediately posterior to the rectus capitis lateralis muscle with a fiber direction more or less opposite to this muscle. The LAO was found in intimate contact with the vertebral artery posteriorly and with the contents of the jugular foramen anteriorly. In all specimens, the origin of this ligament was from the anterolateral aspect of the transverse process of the atlas and the insertion onto the jugular process of the occipital bone. The fibers of the LAO had a mean angle of 26 degrees from the midline. The mean length and width of this ligament was 2.2 and 0.5 cm, respectively. The mean thickness of the LAO was 2 mm. The average tensile strength of this band was 37.5 degrees N. The LAO remained lax with flexion and extension of the craniocervical junction. With contralateral lateral flexion of the craniocervical junction, the LAO became fully taut at a mean of 8 degrees . Partial, but never complete, tautness was observed with rotation of the occipital on the atlas bilaterally. Following sectioning of the LAO, approximately an additional 3 degrees -5 degrees of contralateral lateral flexion was observed. CONCLUSIONS: The LAO is a constant anatomical structure of the craniocervical junction that might be of concern to the clinician. This ligament inhibits lateral flexion of the atlantooccipital joint and its disruption appears to add to instability at this articulation.

The patient with symptoms following resection of a lipomyelomeningocele: do increases in the lumbosacral angle indicate a tethered spinal cord?

OBJECT: The angulation of the sacrum is easily measured. The authors have previously reported on patients who were symptomatic with a diagnosis of myelomeningocele who were found to have changes in their lumbosacral angle (LSA) corresponding to the onset of symptoms indicative of a tethered spinal cord. The aim of this study was to verify this same finding in a group of patients with occult spinal dysraphism (that is, closed neural tube defect). METHODS: A retrospective analysis of 50 consecutive lipomyelomeningocele repair procedures was performed. Data pertaining to 30 age-matched control patients were also analyzed. Measurements were made of the LSA over time in all studied patients harboring lipomyelomeningoceles. Appropriate imaging was available for 25 cases of lipomyelomeningocele (that is, radiographs of the lumbosacral junction were available from the patient's perinatal period and at presentation of symptoms of a tethered spinal cord). Roughly one third of these patients suffered symptoms from a tethered spinal cord at the most recent follow-up examination. Nine patients (36%) were found to have corresponding LSA measurements greater than 70 degrees, and seven (28%) of these patients presented with signs and symptoms of a tethered spinal cord, such as decreased lower-extremity function (two patients), urinary bladder incontinence (three patients), back pain (one patient), and lower-extremity paresthesias (one patient). The LSA measurements were statistically greater (p < 0.05) in the symptomatic patient population than in age-matched control patients and asymptomatic patients. Changes in the LSA in these symptomatic patients ranged from 5 to 24 degrees (mean 13 degrees). Changes in the LSA were noted in only two asymptomatic patients. No single sign or symptom of a tethered spinal cord appeared to correlate to any degree of increase in the LSA. Of the 25 patients excluded from this study because perinatal radiographic images were not available, none was symptomatic at the most recent follow-up examination and none had a grossly exaggerated LSA. CONCLUSIONS: Signs and symptoms indicative of a tethered spinal cord appear to correspond to increases in the LSA. Although the authors do not advocate the use of LSA measurement as the sole indicator of a tethered spinal cord, this imaging finding may prove useful to the clinician as an indication of the tethered spinal cord or as an adjunct in verifying symptomatology in patients harboring a lipomyelomeningocele.

The marginal sinus.

OBJECT: Descriptions of the marginal venous sinus are lacking in the extant medical literature. The aim of this study was to characterize the anatomy of this intracranial venous sinus. METHODS: The authors examined the marginal sinuses in 15 adult cadavers following the injection of latex into the intracranial venous system. The maximal vertical height of the sinuses, which ranged from 7 to 15 mm (mean 10 mm), was located at the lateral aspect of the foramen magnum at or near the region at which the spinal accessory nerve crossed en route to the jugular foramen. In all specimens the sinus tapered as it traveled both anteriorly and posteriorly. Ninety-three percent of the specimens demonstrated significant drainage into the veins of the hypoglossal canal. The hypoglossal nerve rootlets pierced the sinus and its tributaries in 11 (73%) of 15 specimens. The marginal sinus communicated with the basilar venous plexus in 12 (80%) of 15 specimens and with the occipital sinus in all specimens (100%). There was venous communication with the sigmoid sinus in all specimens. The vertebral artery coursed through the marginal sinus as it pierced the posterior atlantooccipital membrane in all left sides and in 87% of the right sides. CONCLUSIONS: These quantitative data will be useful to the neurosurgeon who operates in the region of the marginal sinus.

The use of a sump antibiotic irrigation system to save infected hardware in a patient with a vagal nerve stimulator: technical note.

The authors describe the use of a sump irrigation system that was used to successfully treat the battery implantation site of a vagal nerve stimulator (VNS). Irrigation was composed of a dilution of vancomycin in lactated Ringer's solution. At long-term follow up, the patient has not returned with signs or symptoms of wound infection. She continues to effectively combat her epilepsy with VNS. The authors believe this to be the first description of this technique for salvaging an implanted VNS.