Law enforcement preferences for PTSD treatment and crisis management alternatives.

Evidence-based treatments (EBT) for posttraumatic stress disorder (PTSD) remain underutilized. Analog research, however, indicates that patients may be more amenable to receiving EBT for PTSD than utilization rates suggest. This study sought to extend previous studies by investigating PTSD treatment preferences among law enforcement individuals (i.e., active duty officers, cadets, criminal justice students). We asked 379 participants, with varying trauma histories, to read a police traumatic event and imagine they had developed PTSD. Participants rated the credibility of six treatment options which they might encounter in a treatment setting, and chose their most and least preferred treatments. Next, they evaluated a widely used debriefing intervention aimed at preventing PTSD. Almost 90% of participants chose exposure or Cognitive Processing Therapy as their first or second most preferred treatment, and they rated these interventions as significantly more credible than the other four treatment options. The sample showed ambivalence regarding the perceived efficacy of debriefing but found the rationale credible. This study supports previous analog research indicating that patients may be more interested in EBT than indicated by utilization rates, and suggests that law enforcement departments should consider offering EBT to officers who develop PTSD.

Lesion-induced pseudo-dominance at functional magnetic resonance imaging: implications for preoperative assessments.

OBJECTIVE: To illustrate how lesion-induced neurovascular uncoupling at functional magnetic resonance imaging (fMRI) can mimic hemispheric dominance opposite the side of a lesion preoperatively. METHODS: We retrospectively reviewed preoperative fMRI mapping data from 50 patients with focal brain abnormalities to establish patterns of hemispheric dominance of language, speech, visual, or motor system functions. Abnormalities included gliomas (31 patients), arteriovenous malformations (AVMs) (11 patients), other congenital lesions (4 patients), encephalomalacia (3 patients), and tumefactive encephalitis (1 patient). A laterality ratio of fMRI hemispheric dominance was compared with actual hemispheric dominance as verified by electrocortical stimulation, Wada testing, postoperative and posttreatment deficits, and/or lesion-induced deficits. fMRI activation maps were generated with cross-correlation (P < 0.001) or t test (P < 0.001) analysis. RESULTS: In 50 patients, a total of 85 functional areas were within 5 mm of the edge of a potentially resectable lesion. In 23 of these areas (27%), reduced fMRI signal in perilesional eloquent cortex in conjunction with preserved or increased signal in homologous contralateral brain areas revealed functional dominance opposite the side of the lesion. This suggested possible lesion-induced transhemispheric cortical reorganization to homologous brain regions (homotopic reorganization). In seven patients, however, the fMRI data were inconsistent with other methods of functional localization. In two patients with left inferior frontal gyrus gliomas and in one patient with focal tumefactive meningoencephalitis, fMRI incorrectly suggested strong right hemispheric speech dominance. In two patients with lateral precentral gyrus region gliomas and one patient with a left central sulcus AVM, the fMRI pattern incorrectly suggested primary corticobulbar motor dominance contralateral to the side of the lesion. In a patient with a right superior frontal gyrus AVM, fMRI revealed pronounced left dominant supplementary motor area activity in response to a bilateral complex motor task, but right superior frontal gyrus perilesional hemorrhage and edema subsequently caused left upper-extremity plegia. Pathophysiological factors that might have caused neurovascular uncoupling and facilitated pseudo-dominance at fMRI in these patients included direct tumor infiltration, neovascularity, cerebrovascular inflammation, and AVM-induced hemodynamic effects. Sixteen patients had proven (1 patient), probable (2 patients), or possible (13 patients) but unproven lesion-induced homotopic cortical reorganization. CONCLUSION: Lesion-induced neurovascular uncoupling causing reduced fMRI signal in perilesional eloquent cortex, in conjunction with normal or increased activity in homologous brain regions, may simulate hemispheric dominance and lesion-induced homotopic cortical reorganization.

Complication rate of transtemporal hydroxyapatite cement cranioplasties: a case series review of 76 cranioplasties.

OBJECTIVE: The objective of this study was to evaluate the complication rate of transtemporal cranioplasties using hydroxyapatite cement (HAC) for repair. STUDY DESIGN: We conducted a retrospective case review of patients receiving HAC cranioplasties in the Acoustic Neuroma and Skull Base Surgery Program between July 1998 and December 2002. SETTING: This study was conducted at a tertiary referral center. PATIENTS: A total of 76 HAC cranioplasties were performed in 72 patients undergoing lateral skull base surgery. Patients undergoing anterior skull base surgery or those in which HAC was used for other reconstructive purposes were excluded from the study. INTERVENTIONS: We studied transtemporal approaches for otologic procedures requiring cranioplasty. MAIN OUTCOME MEASURES: Main outcomes measures consisted of complications requiring medical or surgical intervention. RESULTS: Of the 76 HAC cranioplasties, two cranioplasty grafts became infected, requiring explantation. The first case involved a wound infection that extended into and involved the HAC graft; the second involved seeding of the HAC graft after meningitis after a percutaneous, endoscopic gastrostomy tube placement performed several days after the primary skull base surgery. This gives our series a wound infection incidence rate of 1.3% and an overall complication incidence rate of 2.63%. CONCLUSIONS: This retrospective review provides the largest series to date evaluating the incidence of infection in HAC cranioplasties. Despite having a much larger series, our complication rate is the lowest published rate of HAC cranioplasty explantation, and the incidence of superficial wound infections reported here is consistent with the published data for neurosurgical and neurotologic procedures.

Evaluation of photodynamic therapy near functional brain tissue in patients with recurrent brain tumors.

INTRODUCTION: Photodynamic therapy (PDT) involves the selective retention of a photosensitizer that upon activation with light mediates tumor cell destruction via the production of singlet oxygen. This study evaluates the toxicity of PDT and a new light-delivery device based on light-emitting diode (LED) technology in selected patients with brain tumors. METHODS: Twenty patients with recurrent malignant brain tumors received 22 treatments with PDT. Sixteen tumors were supratentorial and four tumors were infratentorial. Patients received IV Photofrin 24 h prior to light exposure starting at 0.75 mg kg(-1). Laser and LED arrays were used to deliver 100 J cm(-2) of light to the sensitized tumors. Fourteen patients received PDT with a laser-balloon adapter, two via interstitial optical fibers and five patients had LED based PDT. At the maximum Photofrin dose of 2.0 mg kg(-1) five patients received laser-balloon adapter light and five patients received LED light. In addition, three patients received LED light with 0.25 mg kg(-1) of Visudine, a benzoporphyrin derivative (BPD). Quantitative analysis of toxicity and time to progression was performed. RESULTS: Two patients had toxicity consisting of ataxia and facial weakness after treatment with interstitial fibers. Escalating doses of Photofrin were tolerated to the maximum dose of 2.0 mg kg(-1). BPD did not result in additional toxicity. PDT in the posterior fossa or near eloquent brain was tolerated using the LED or laser-balloon adapter. All patients had tumor responses as documented by MRI scan and the mean time to tumor progression after PDT was 67 weeks. CONCLUSION: PDT with LED balloon adapters (also tunable dye laser) has acceptable toxicity in brain tumor patients. Future studies using more effective photosensitizers could improve local recurrence control.

Meningitis due to Enterobacter aerogenes subsequent to resection of acoustic neuroma and percutaneous endoscopic gastrostomy tube placement: a rare nosocomial event.

We present a case of meningitis after percutaneous endoscopic gastrostomy (PEG) tube placement subsequent to acoustic neuroma resection and cranioplasty. Four days following PEG tube placement, the patient developed Enterobacter aerogenes meningitis, requiring explantation of infected cranioplasty material. His condition subsequently improved. Etiology and future intervention strategies are discussed.

Passband-shifting filters through postgrowth modification of filter optical thickness.

We describe a postgrowth method to produce passband filters with different center wavelengths from a single growth run by irreversibly changing the refractive index of a layer or a series of layers within the filter. This leads to a new type of filter, the passband-shifting filter, whose center wavelength can be irreversibly shifted from lambda0 to lambda0 - deltalambda after the filter has been grown. The passband shift can be controlled exactly by proper design of the multilayer. We present the theory behind passband-shifting-filter design along with transfer-matrix simulations and preliminary experimental results for a two-cavity filter, using lateral oxidation of AlxGa1-x As-based materials to effect the passband shift.

Post-radiation dedifferentiation of meningioma into osteosarcoma.

BACKGROUND: A number of osteoblastic meningiomas, primary osteosarcomas of the meninges, and post-radiation osteosarcomas of the head have been reported. However, postradiation dedifferentiation of meningioma into osteosarcoma has not been reported previously. CASE PRESENTATION: In 1987 a caucasian man, then 38 years old, presented with a pituitary macroadenoma. He underwent a subtotal resection of the tumor and did well until 1990 when a recurrent tumor was diagnosed. This was treated with subtotal resection of the tumor, followed by radiation therapy for six weeks to a total of 54 Gy. He was considered "disease-free" for nearly ten years. However, most recently in July 2000, he presented with a visual field deficit due to a second recurrence of his pituitary macroadenoma, now with suprasellar extension. At this time, as an incidental finding, a mass attached to the dura was noted in the left parietal hemisphere. This dura-based mass had grown rapidly by January 2001 and was excised. It showed histological, immunohistochemical, and electron microscopic features of malignant meningioma and osteosarcoma with a sharp demarcation between the two components. CONCLUSIONS: We report a rare case of a radiation induced dedifferentiation of meningioma into osteosarcoma, which has not been reported previously.

Endoscopy in neuro-otologic surgery.

Endoscopy offers several distinct advantages over the operating microscope during neuro-otologic surgery that make it an excellent adjunctive tool to the microscope or independent modality during cranial base surgery. The high magnification gives excellent definition of perforating blood vessels, cranial nerves, and neural structures, which in many cases is superior to that achieved with the microscope. Furthermore, the use of angled or flexible endoscopes allows one to look around corners and behind anatomic structures blocking the view seen via a 0 degree microscope. Endoscopy also has the theoretical advantage that a less invasive operative procedure is required, which should reduce the operative morbidity. Several notable disadvantages of endoscopy include the problems associated with blood soiling the endoscope, making visualization difficult or impossible, the lack of readily available instrumentation designed specifically for endoscopic neuro-otology, and the poor overview of the operative field. This last point is an important one because the endoscope is placed adjacent to the lesion and does not allow one to look backward to prevent [figure: see text] injury to structures next to the shaft of the telescope. Furthermore, the surgeon must be cognizant of potential thermal injury to structures caused by the heat generated by the light source. The present endoscopic technology limits the image that the surgeon sees to two dimensions, which results in certain unique problems when operating in a three-dimensional milieu. Because of this, there is a steep learning curve to acquire endoscopic dexterity and three-dimensional orientation. Finally, bimanual operation requires the use of an articulated endoscope holder or the commitment of the co-surgeon to hold the endoscope. One of the limitations of the operative microscope is that the angle of view is determined by the distance of the lens to the skull, retractor, or obstructing tissue, which is a function of the lens focal length; the longer the focal length, the narrower the viewing angle. During most microsurgical procedures, the focal distance varies between 200 and 400 mm. Using a previous analogy, if one looks through a door's keyhole at close range, nearly the entire room on the opposite side of the door can be seen, although nothing can be seen when the hole is viewed from a long distance. This is similar to what happens when using the endoscope with focal lengths ranging from 5 to 20 mm: a wider angle of view can be achieved. Based on their, experience the authors believe that endoscopes can be used safely during neuro-otologic surgery. As an adjunct to or substitution for the operative microscope, this modality does improve visualization of bony, neural, and vascular structures while minimizing cerebellar retraction.

The ascending pharyngeal artery: branches, anastomoses, and clinical significance.

Neuroradiologists generally do not fully appreciate the importance of the territory of the ascending pharyngeal artery. The ascending pharyngeal artery is a small but important artery that supplies multiple cranial nerves and anastomotic channels to the anterior and posterior cerebral circulations. Several disease processes in the head and neck involve the ascending pharyngeal artery. To evaluate and treat such diseases, it is necessary for neuroradiologists not only to know selective angiography and embolization techniques, but also the territory of the ascending pharyngeal artery, anastomoses, and vascular supply to the vasa nervorum of lower cranial nerves. Herein, the normal angiographic anatomy of the ascending pharyngeal artery, its relationship with neighboring territories, its importance in clinical situations, and research models are reviewed.

Chiari type I malformation revisited: diagnosis and treatment.

BACKGROUND: Chiari type I malformations (Chiari I) are congenital deformities where caudal migration of the cerebellar tonsils through the foramen magnum compresses the cerebellum and cervicomedullary junction (lower brainstem and upper cervical spinal cord). Associations with chronic fatigue syndrome, fibromyalgia, orthostatic intolerance, and other neurologic syndromes have been proposed along with the current plethora of known symptoms of this disease process. In advanced cases, Chiari I malformations can lead to significant neurologic deficit and be the cause of permanent nervous system damage. REVIEW SUMMARY: This article focuses on the clinical diagnosis and treatment of patients with Chiari I, including a discussion on the possible mechanisms of Chiari I with a review of present diagnostic tests, indications for treatment, and appraisal of surgical outcome. CONCLUSIONS: Future radiological advances and research will undoubtedly be directed to better understanding of the pathology of the Chiari malformation and more effective medical and surgical treatment.

Chiari type I malformation: overview of diagnosis and treatment.

Chiari Type I malformation (Chiari I) is a congenital hindbrain anomaly characterized by downward displacement of the cerebellar tonsils through the foramen magnum. This can lead to compression of cerebellar components, the lower brainstem, and the upper cervical spinal cord. In turn, a variety of neurological deficits and permanent nervous system damage may evolve. This review article discusses the etiology, diagnosis, and treatment of patients with Chiari I malformation. Its protean manifestations cause significant overlap with multiple sclerosis, chronic fatigue syndrome, and numerous other conditions. Accordingly, the diagnosis of Chiari I is difficult to establish by clinical evaluation alone. Demonstration of the characteristic hindbrain abnormalities, however, is easily accomplished with magnetic resonance imaging. Neuroimaging should therefore be considered in patients with cerebellar, brainstem, and cervical cord dysfunction. Surgical treatment is indicated in symptomatic patients with radiographic evidence of hindbrain abnormalities. Posterior fossa decompression has also been performed in patients with fibromyalgia and chronic fatigue syndrome based solely on overlapping symptoms with Chiari I. This practice remains controversial. Appraisal of surgical outcome requires postoperative neuroimaging and long-term patient follow-up to assess the permanency of improvement. Preliminary study results of the impact of surgical technique on patient outcome are reported. Ongoing research is devoted to a better understanding of the pathophysiology of Chiari I malformation and the development of more effective medical and surgical treatments.