Surgical Management of Vertex Epidural Hematoma: Technical Case Report and Literature Review.

BACKGROUND: Vertex epidural hematoma (VEH) is an uncommon presentation of extra-axial hematomas. It can represent a surgical dilemma regarding when and how to operate, particularly considering the potential implication of the superior sagittal sinus (SSS). OBJECTIVE: Here, we illustrate the surgical technique for VEH as well as a review of the existing literature. METHODS: A 60-year-old man sustained a ground-level fall resulting in complete diastasis of the sagittal suture with underlying large VEH causing significant mass effect on the SSS and bihemispheric convexities. Twenty-four hours later, the patient deteriorated, with decreased level of alertness and worsening asymmetric paresis on his lower extremities. He subsequently underwent surgical evacuation of the hematoma, decompression of the SSS, and fracture repair. A modified bicoronal approach, with bilateral parasagittal craniotomies, was performed. A central island of bone was left intact to spare the diastatic fracture from the craniotomies. This was done to ensure a stable anchor point for tacking-up the underlying displaced dura and SSS. The central bone prevents extensive bleeding from the diastatic fracture and eliminates the risk of further blood reaccumulation and tearing of a possible injured sinus during bone flap elevation. RESULTS: The technique performed allowed us to evacuate completely the hematoma while preserving the SSS and repairing the sagittal suture to avoid further bleeding. Complete neurologic recovery of the patient occurred after VEH evacuation. CONCLUSIONS: Because of its rare nature, VEH represents a surgical challenge. Because neurosurgeons encounter this condition relatively infrequently, literature regarding the medical and surgical management of this entity is warranted.

Stereotactic radiosurgery for essential tremor: Retrospective analysis of a 19-year experience.

BACKGROUND: Essential Tremor (ET) is a common movement disorder that can be disabling. Initial treatment is in the form of medical therapies. Patients with medically refractory ET seek surgical intervention which include radiofrequency thalamotomy, deep brain stimulation, and radiosurgical thalamotomy. Radiosurgical thalamotomy is a minimally invasive surgical option which is especially valuable for elderly and high surgical risk patients. OBJECTIVE: The purpose of this study was to retrospectively analyze the outcomes of stereotactic radiosurgery for patients suffering from medically refractory essential tremor. METHODS: During a 19-year period (1996-2015), 73 patients underwent gamma knife thalamotomy for intractable essential tremor. A median central dose of 140 Gy (range, 130-150) was delivered to the nucleus ventralis intermedius through a single 4-mm isocenter. We used the Fahn-Tolosa-Marin clinical tremor rating scale to score tremor, handwriting, drawing, and ability to drink fluids. The median time to last follow-up was 28 months (range, 6-152). RESULTS: After gamma knife thalamotomy, 93.2% improved in tremor. Forty-four patients (60.3%) experienced tremor arrest or barely perceptible tremor. Eighteen patients (24.7%) noted tremor arrest and complete restoration of motor function. Tremor improvement was sustained at last follow-up in 96% of patients who experience tremor relief. Mean tremor score improved from 3.19 before to 1.27 after gamma knife thalamotomy (P < 0.0001). Mean handwriting score improved from 2.97 to 1.25 (P < 0.0001). Mean drawing score improved from 3.16 to 1.26 (P < 0.0001). Mean drinking score improved from 3.14 to 1.56 (P < 0.0001). Imaging follow-up showed three types of lesions: enhancing lesion, streaking along internal capsule on fluid-attenuated inversion recovery, and significant reactive changes. Three patients (4%) experienced temporary adverse radiation effects. CONCLUSION: Radiosurgery is a safe and valuable treatment option for medically refractory essential tremor, especially for the elderly or those with high surgical risk for DBS or radiofrequency thalamotomy. © 2017 International Parkinson and Movement Disorder Society.

Successful Manual Aspiration Thrombectomy in a Pediatric Patient.

BACKGROUND: Timely recognition of stroke at major pediatric medical centers is improving, and although treatment guidelines for pediatric stroke exist, no extensive study establishing the efficacy of surgical or thrombolytic treatment has been completed. Extrapolation of adult guidelines to pediatric patients remains the mainstay of treatment in the absence of adequate information regarding safety and efficacy in children. Recent trials have demonstrated revascularization and clinical improvement after endovascular retrieval therapy in adults with acute large vessel occlusive stroke. Furthermore, successful mechanical thrombectomy using a variety of techniques has been documented in numerous children and adolescents. PATIENT DESCRIPTION: We present a 15-year-old boy with altered mental status and left hemiparesis due to acute ischemic stroke secondary to blockage of the right internal carotid artery terminus, most likely precipitated by end-stage heart failure and cardiac embolism. Mechanical aspiration thrombectomy using the Penumbra aspiration catheter without any adjunct surgical equipment or thrombolytic therapy was used to remove thrombus and treat the patient's acute ischemic stroke. He experienced complete artery recanalization with a Thrombolysis in Cerebral Infarction (TICI) score of 2C after the procedure. He also exhibited an 8 point improvement in his pediatric National Institutes of Health Stroke Scale score within 24 hours. CONCLUSIONS: Mechanical aspiration thrombectomy is commonly used in adult hospitals but infrequently employed in pediatric patients with arterial ischemic stroke. Given its efficacy in our patient, we encourage a larger systematic trial to evaluate the use of mechanical thrombectomy in pediatric patients with acute ischemic stroke.

Atlanto-occipital Instability Following Endoscopic Endonasal Approach for Lower Clival Lesions: Experience With 212 Cases.

BACKGROUND: The endoscopic endonasal approach (EEA) for craniocervical lesions involving the lower clivus and occipital condyles carries an unclear risk of atlanto-occipital (AO) instability requiring arthrodesis. OBJECTIVE: Elucidate risk factors for AO instability following EEA for clival lesions. METHODS: We reviewed patients with clival tumors who underwent EEA at our institution between 2002 and 2012. Resection of the lower clivus, foramen magnum, AO joint, and occipital condyles were evaluated on fine-cut postoperative computed tomography. RESULTS: Two hundred twelve patients (mean age 47.9 years, 57.1% male) underwent transclival EEA for lower clival lesions. In addition to the lower clivus, resection involved the condyle in 14.2% of patients, the foramen magnum in 16.5%, and the AO joint in 1.4%. Quantification of condyle resection revealed complete resection in 3 cases, 75% resection in 8 cases, 50% resection in 6 cases, and 25% resection in 13 cases. Seven of these patients had EEA combined with an open, far-lateral approach. In total, 7 patients required arthrodesis following EEA (3.3%), 4 of them after a combined approach. All patients who underwent arthrodesis had primary bone tumors such as chordoma, chondrosarcoma, or osteosarcoma (P = .022). Degree of condyle resection was a significant factor predisposing to occipitocervical instability (P = .001 and P < .001 for 75% and 100% condyle resection, respectively). Use of a combined approach was significantly associated with arthrodesis (P < .001). CONCLUSION: EEA resection of the occipital condyles that results in greater than 75% condyle resection or EEA in combination with an open approach significantly increases the risk of AO instability and likely necessitates AO fixation. ABBREVIATIONS: AO, atlanto-occipitalEEA, endoscopic endonasal approachOC, occipitocervical.

Thrombosis and spontaneous recanalization of a giant intracranial aneurysm: diagnostic and management pearls in a pediatric patient.

The authors present the case of a boy who was successfully managed through the spontaneous thrombosis of a cavernous internal carotid artery (ICA) aneurysm, the subsequent occlusion of the ICA, its recanalization, and ultimate endovascular sacrifice, using only two angiograms because of the diagnostic capability of CT angiography. Spontaneous recanalization of the ICA following occlusion in the setting of a giant aneurysm has not been previously reported.

Gamma Knife thalamotomy for tremor in the magnetic resonance imaging era.

OBJECT: The surgical management of disabling tremor has gained renewed vigor with the availability of deep brain stimulation. However, in the face of an aging population of patients with increasing surgical comorbidities, noninvasive approaches for tremor management are needed. The authors' purpose was to study the technique and results of stereotactic radiosurgery performed in the era of MRI targeting. METHODS: The authors evaluated outcomes in 86 patients (mean age 71 years; number of procedures 88) who underwent a unilateral Gamma Knife thalamotomy (GKT) for tremor during a 15-year period that spanned the era of MRI-based target selection (1996-2011). Symptoms were related to essential tremor in 48 patients (19 age ≥ 80 years and 3 age ≥ 90 years), Parkinson disease in 27 patients (11 age ≥ 80 years [1 patient underwent bilateral procedures]), and multiple sclerosis in 11 patients (1 patient underwent bilateral procedures). A single 4-mm isocenter was used to deliver a maximum dose of 140 Gy to the posterior-inferior region of the nucleus ventralis intermedius. The Fahn-Tolosa-Marin clinical tremor rating scale was used to grade tremor, handwriting, and ability to drink. The median follow-up was 23 months. RESULTS: The mean tremor score was 3.28 ± 0.79 before and 1.81 ± 1.15 after (p < 0.0001) GKT; the mean handwriting score was 2.78 ± 0.82 and 1.62 ± 1.04, respectively (p < 0.0001); and the mean drinking score was 3.14 ± 0.78 and 1.80 ± 1.15, respectively (p < 0.0001). After GKT, 57 patients (66%) showed improvement in all 3 scores, 11 patients (13%) in 2 scores, and 2 patients (2%) in just 1 score. In 16 patients (19%) there was a failure to improve in any score. Two patients developed a temporary contralateral hemiparesis, 1 patient noted dysphagia, and 1 sustained facial sensory loss. CONCLUSIONS: Gamma Knife thalamotomy in the MRI era was a safe and effective noninvasive surgical strategy for medically refractory tremor in the elderly or those with contraindications to deep brain stimulation or stereotactic radiofrequency (thermal) thalamotomy.

Prolonged vision return after radiosurgery for an optic nerve-sheath meningioma.

OBJECTIVE: To report a case of prolonged vision return after stereotactic radiosurgery for an optic nerve-sheath meningioma. DESIGN: Case report. INTERVENTION: Ophthalmologic examination followed by stereotactic radiosurgery for an optic nerve-sheath meningioma. MAIN OUTCOME MEASURES: Ophthalmologic examination and MRI findings. RESULTS: We report the case of 59-year-old female with visual deterioration and progressive proptosis five years after subtotal resection of a left optic nerve-sheath meningioma. Because of progression to blindness (no light perception), the patient underwent Gamma Knife® stereotactic radiosurgery to the intraorbital meningioma in order to achieve tumor-growth control. Remarkably, within one year, her vision in the ipsilateral eye improved to 20/25, and her MRI scan showed significant tumor regression. Excellent vision persisted for eight years. After that, the left eye vision again decreased to hand movement only. At ten years after radiosurgery her ophthalmological exam confirmed severe optic neuropathy. CONCLUSIONS: Radiosurgery provided a paradoxical benefit in this patient who had complete blindness but had restoration of vision for more than eight years. Delayed eventual visual loss likely resulted from optic nerve long-term adverse radiation effect despite persistent long-term tumor growth control.

Vasospasm after subarachnoid hemorrhage in haptoglobin 2-2 mice can be prevented with a glutathione peroxidase mimetic.

Vasospasm after subarachnoid hemorrhage (SAH) is attributable to inflammation and oxidative stress associated with extracellular hemoglobin (Hb). Haptoglobin (Hp) binds free Hb and the Hp-Hb complex is cleared by macrophages, and the Hp-2 isoform of Hp is associated with more oxidative stress and more severe vasospasm. We hypothesized that treatment with an anti-oxidant, the glutathione peroxidase mimetic SYI-2074, would reduce vasospasm after SAH in Hp-2 mice. We found that SAH induced significant vasospasm in Hp-2 mice (lumen patency reduced to 65.9%), but no vasospasm was seen in mice that received SYI-2074 after SAH (lumen patency of 98.7%). We conclude that vasospasm after SAH in Hp-2 mice can be prevented with SYI-2074, suggesting that oxidative stress contributes significantly to vasospasm.

Characterization of a novel gain of function glucocorticoid receptor knock-in mouse.

Glucocorticoids (GCs) exert profound influences on many physiologic functions by virtue of their diverse roles in growth, development, and maintenance of homeostasis. We previously created a novel gain of function in the human glucocorticoid receptor (hGR), hGRM604L, which is active at GC concentrations 5-10-fold lower than wild-type GR. To gain a greater insight into GC physiology in vivo, we inserted this mutant GR (GRM610L in mice) into mice via homologous recombination. Mice expressing the allele are phenotypically normal with respect to GC function. However, corticosterone levels, ACTH levels, and adrenocortical size are markedly reduced, suggesting they are phenotypically normal because the mutant GR alters the basal regulation of the hypothalamic-pituitary-adrenal axis. We demonstrate via physiologic and immunologic studies that GRM610L mice have increased sensitivity to GCs in vivo. Sensitivity to the actions of endogenous GCs may be an important factor underlying the development of many human diseases including hypertension, obesity, and diabetes. Our model may provide a new and powerful tool for the study of GC physiological and pathological processes in vivo.

Detection of injury-induced vascular remodeling by targeting activated alphavbeta3 integrin in vivo.

BACKGROUND: The alpha(v)beta3 integrin plays a critical role in cell proliferation and migration. We hypothesized that vascular cell proliferation, a hallmark of injury-induced remodeling, can be tracked by targeting alpha(v)beta3 integrin expression in vivo. METHODS AND RESULTS: RP748, a novel 111In-labeled alpha(v)beta3-specific radiotracer, was evaluated for its cell-binding characteristics and ability to track injury-induced vascular proliferation in vivo. Three groups of experiments were performed. In cultured endothelial cells (ECs), TA145, a cy3-labeled homologue of RP748, localized to alpha(v)beta3 at focal contacts. Activation of alpha(v)beta3 by Mn2+ led to increased EC binding of TA145. Left common carotid artery wire injury in apolipoprotein E-/- mice led to vascular wall expansion over a period of 4 weeks. RP748 (7.4 MBq) was injected into groups of 9 mice at 1, 3, or 4 weeks after left carotid injury, and carotids were harvested for autoradiography. Relative autographic intensity, defined as counts/pixel of the injured left carotid area divided by counts/pixel of the uninjured right carotid area, was higher at 1 and 3 weeks (1.8+/-0.1 and 1.9+/-0.2, respectively) and decreased significantly by 4 weeks after injury (1.4+/-0.1, P<0.05). Carotid alpha(v) and beta3 integrin expression was maximal at 1 week and decreased by 4 weeks after injury. The proliferation index, as determined by Ki67 staining, followed a temporal pattern similar to that of RP748 uptake. Dynamic gamma imaging demonstrated rapid renal clearance of RP748. CONCLUSIONS: RP748 has preferential binding to activated alpha(v)beta3 integrin and can track the injury-induced vascular proliferative process in vivo.