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1.
J Neurol Surg Rep ; 80(1): e10-e13, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30941279

RESUMO

Objectives To present a rare case of traumatic facial neuroma involving the geniculate ganglion and review relevant literature. Patient Thirty-year-old man. Intervention Microsurgical resection via combined mastoid-middle fossa approach with great auricular nerve interpositional graft. Main Outcome Measures Patient demographics and pre- and postoperative facial nerve function. Results A 30-year-old man with a reported history of prior Bell's palsy developed progressive complete (House-Brackmann VI) right facial paralysis following blunt trauma. Imaging was strongly suggestive of a geniculate ganglion hemangioma. As the patient had no spontaneous improvement in his poor facial function over the course of 9 months, he underwent resection of the facial nerve lesion with great auricular nerve graft interposition via a combined mastoid-middle fossa approach. Histopathology demonstrated disorganized fascicles, with axonal clustering reminiscent of sprouting/regeneration following trauma. No cellular proliferation or vascular malformation was present. Conclusion Traumatic facial nerve neuromas can occur following temporal bone trauma and can closely mimic primary facial nerve tumors. Akin to the management of geniculate ganglion hemangioma and schwannoma, preoperative facial function largely dictates if and when surgery should be pursued.

3.
Oper Neurosurg (Hagerstown) ; 13(4): 448-452, 2017 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-28838106

RESUMO

BACKGROUND: Extradural approach to the cavernous sinus, the "Dolenc" approach recognizing its developing Dr. Vinko Dolenc, is a critically important skull base approach. However, resection of the lateral wall of the cavernous sinus, most commonly for cavernous sinus meningiomas, results commonly in a defect that often cannot be reconstructed in a water-tight fashion. This may result in troublesome pseudomeningocele postoperatively. OBJECTIVE: To describe a technique designed to mitigate the development of pseudomeningocele. METHODS: We found the Dolenc approach critical for resection of cavernous lesions. However, a number of pseudomeningoceles were managed with prolonged external pressure wrapping in the early cohort. Therefore, we incorporated subgaleal to muscular sutures, which were designed to close this potential space and retrospectively analyzed our results. RESULTS: Twenty-one patients treated with a Dolenc approach and resection of the lateral wall of the cavernous sinus over a 2-year period were included. Prior to incorporation of this technique, 12 patients were treated and 3 (25%) experienced postoperative pseudomeningoceles requiring multiple clinic visits and frequent dressing. After incorporation of subgaleal retention sutures, no patient (0%) experienced this complication. CONCLUSION: Although basic, subgaleal to temporalis muscle retention sutures likely aid in eliminating this potential dead space, thereby preventing patient distress postoperatively. This technique is simple and further emphasizes the importance of dead space elimination in complex closures.


Assuntos
Bandagens , Seio Cavernoso/cirurgia , Craniotomia/métodos , Base do Crânio/cirurgia , Técnicas de Sutura , Seio Cavernoso/diagnóstico por imagem , Seguimentos , Gadolínio , Humanos , Hidrocefalia/etiologia , Imagem por Ressonância Magnética , Neoplasias Meníngeas/diagnóstico por imagem , Neoplasias Meníngeas/cirurgia , Meningioma/cirurgia , Procedimentos Neurocirúrgicos , Estudos Retrospectivos
4.
J Neurosurg Sci ; 2017 May 31.
Artigo em Inglês | MEDLINE | ID: mdl-28565897

RESUMO

BACKGROUND: Management of a patient with an unruptured intracranial aneurysm (UIA) who has a history of malignancy can be challenging due to considerations related to the natural history of the aneurysm and risk of recurrence or progression of malignancy. The current study presents our experience with both conservative management and interventional treatment of patients with UIAs and a remote or recent history of cancer. METHODS: Consecutive patients with a history of malignancy and UIA were classified into the following groups: Group I (diagnoses of both UIA and cancer within 3 years) and Group II (known cancer with new UIA diagnosed ≥ 3 years after cancer). Patient demographics, clinical characteristics, aneurysm/treatment characteristics, and outcomes were collected prospectively. We studied the following outcomes: perioperative and mid-/long-term complications, aneurysm rupture, retreatment/recurrence rates, long-term neurological outcome, and possible impact of cancer history on decision-making for treatment. RESULTS: A total of 122 patients were included in this study (55 in Group I and 67 in Group II). Patients in Group I underwent aneurysm treatment significantly less often than those in Group II (20.0% versus 46.3%, P=0.002). There was no difference in neurological morbidity rates between the two groups after a mean follow-up of 22.3 months (3.6% versus 3.0%, P=0.29). Overall, untreated patients experienced an annualized rupture rate of 1.6% (95% CI=0.0%-3.4%, 3/187.6 ruptures/person years). CONCLUSIONS: Patients with an UIA and a history of cancer should be considered for management with either conservative management or invasive techniques. The optimal UIA management is defined on a case-by-case basis carefully comparing the prognosis of the patient's malignancy with the natural history of the aneurysm and the risk of interventional treatment.

5.
Neurosurg Focus ; 41(4): E8, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27690651

RESUMO

OBJECTIVE Hypothalamic hamartomas (HHs) are associated with gelastic seizures and the development of medically refractory epilepsy. Magnetic resonance imaging-guided laser interstitial thermal therapy (MRg-LITT) is a minimally invasive ablative treatment that may have applicability for these deep-seated lesions. Here, the authors describe 3 patients with refractory HHs who they treated with MRg-LITT. METHODS An institutional review board-approved prospective database of patients undergoing Visualase MRg-LITT was retrospectively reviewed. Demographic and historical medical data, including seizure and medication histories, previous surgeries, procedural details, and surgical complications, along with radiological interpretation of the HHs, were recorded. The primary outcome was seizure freedom, and secondary outcomes included medication reduction, seizure frequency, operative morbidity, and clinical outcome at the latest follow-up. RESULTS All 3 patients in the multi-institutional database had developed gelastic seizures related to HH at the ages of 7, 7, and 9 years. They presented for further treatment at 25, 28, and 48 years of age, after previous treatments with stereotactic radiosurgery in all cases and partial hamartoma resection in one case. One ablation was complicated by a small tract hemorrhage, which was stable on postoperative imaging. One patient developed hyponatremia and experienced weight gain, which were respectively managed with fluid restriction and counseling. At the most recent follow-up at a mean of 21 months (range 1-32 months), one patient was seizure free while another had meaningful seizure reduction. Medication was reduced in one case. CONCLUSIONS Adults with gelastic seizures despite previous treatments can undergo MRg-LITT with reasonable safety and efficacy. This novel therapy may provide a minimally invasive alternative for primary and recurrent HH as the technique is refined.


Assuntos
Hamartoma/diagnóstico por imagem , Hamartoma/cirurgia , Doenças Hipotalâmicas/diagnóstico por imagem , Doenças Hipotalâmicas/cirurgia , Terapia a Laser/métodos , Imagem por Ressonância Magnética , Adulto , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
6.
Acta Neurochir (Wien) ; 158(11): 2053-2059, 2016 11.
Artigo em Inglês | MEDLINE | ID: mdl-27644699

RESUMO

BACKGROUND: Internal carotid artery bifurcation aneurysms (ICAbifAs) present unique challenges to endovascular and surgical operators, and little is known about their natural history. We reviewed our institution's experience with ICAbifAs studying outcomes of surgical and endovascular management and natural history. METHODS: Consecutive patients with unruptured ICAbifAs evaluated and/or treated over an 8-year interval were studied. Baseline demographics, neurovascular risk factors, aneurysm location and size, clinical presentation, treatment recommendations, and outcomes were prospectively collected and retrospectively analyzed. Continuous variables were compared with Student's t test and categorical variables with Chi-square tests. RESULTS: Fifty-nine patients with 61 unruptured ICAbifAs were included. Seven aneurysms were treated surgically (11.5 %), 22 underwent endovascular treatment (36 %), and 32 were managed conservatively (52.5 %). In the surgical group, short- and long-term complete aneurysm occlusion rates were 100 % with no cases of perioperative or long-term permanent morbidity or treatment-related mortality. In the endovascular group, two patients (11.7 %) with giant aneurysms had perioperative thromboembolic events with transient morbidity. There was one case of aneurysm rupture at follow-up in a giant aneurysm treated with partial coil embolization. Complete/near-complete occlusion rates were 63 %. There was one case of aneurysm rupture after 114 aneurysm-years of follow-up in the conservative management group (0.89 %/year), but no ruptures were observed in small aneurysms selected for conservative management. CONCLUSIONS: Unruptured small ICAbifAs have a benign natural history. In patients selected for treatment, excellent results can be achieved in the vast majority of patients with judicious use of endovascular and surgical therapy.


Assuntos
Aneurisma Roto/cirurgia , Artéria Carótida Interna/cirurgia , Embolização Terapêutica/efeitos adversos , Aneurisma Intracraniano/cirurgia , Complicações Pós-Operatórias , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
7.
Global Spine J ; 6(5): 447-51, 2016 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-27433428

RESUMO

STUDY DESIGN: Retrospective study. OBJECTIVE: Efficient use of operating room time is important, as delays during induction or recovery increase time not spent operating while in the operating room. We identified factors that increase anesthetized, nonoperative time by utilizing a database of over 5,000 consecutive neurosurgical spine cases. METHODS: Surgical records were searched to identify all spine surgeries performed between January 2010 and July 2012. Anesthetized, nonoperative time was calculated from the anesthesia record and compared with both patient and procedure characteristics to determine any significant relationships. RESULTS: There were 5,515 surgical cases with a mean age of 60.5 and mean body mass index (BMI) of 29.7; 3,226 (58%) were male subjects. There were 1,176 (21%) fusion cases, and level of pathology was predominantly lumbar (4,010 cases, 73%). Fusion cases had a significantly longer total anesthetized, nonoperative time (fusion: 98 minutes, nonfusion: 76 minutes, mean difference: 22 minutes, p < 0.0001). Significant factors affecting anesthetized, nonoperative time in nonfusion cases include age greater than 65 years (mean difference 5 minutes, p < 0.0001), American Society of Anesthesiologists (ASA) grade, and BMI (BMI < 25: 72 ± 1.2 minutes, BMI 25 to 29: 74 ± 0.6 minutes, BMI 30 to 39: 79 ± 0.6 minutes, BMI 40 + : 87 ± 1.8 minutes, p < 0.0001). Similarly, for fusion operations, age > 65 years significantly increased nonoperative time (mean difference 6 minutes, p < 0.01), as did increasing ASA (mean difference 9 minutes, p < 0.0001) and increasing BMI. CONCLUSION: Patient and surgical factors, including ASA grade, BMI, level of pathology, and surgical approach, have noticeable effects on anesthetized, nonoperative times in spine surgery.

8.
J Neuroradiol ; 43(5): 309-16, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27137085

RESUMO

INTRODUCTION: Intracranial infectious aneurysms (IIAs), or mycotic aneurysms are rare, representing between 0.7% and 5.4% of all intracranial aneurysms. To clarify the safety and efficacy of endovascular treatment of IIAs, we conducted a systematic review of the literature analyzing periprocedural and long-term clinical and angiographic outcomes. METHODS: A comprehensive review of the literature for studies with ≥3 patients related to endovascular treatment of IIAs published through September 2015 was performed. Random-effects meta-analysis was used to pool the following outcomes: complete occlusion, technical success, aneurysm recurrence, rebleeding, perioperative mortality, iatrogenic rupture, perioperative stroke, procedure-related morbidity and mortality, long-term neurological morbidity and mortality, and overall good neurological outcome. RESULTS: We included 11 non-comparative studies with 86 target IIAs. Complete occlusion rates were 95.3% (95% CI=91.2-99.4%). Recurrence occurred in 7.9% (95% CI=2.7-13.0%). Rebleeding occurred in 5.8% (95% CI=1.4-10.3%) of patients. Procedure-related morbidity was 12.6% (95% CI=6.1-19.2%) and procedure-related mortality was 6.1% (95% CI=1.5-10.8%). Long-term good neurological outcome was 68.0% (95% CI=55.1-80.9%). CONCLUSION: Our meta-analysis demonstrated that endovascular treatment is technically feasible and effective with high rates of IIA occlusion. Despite the comorbidities of patients, endovascular approach was associated with acceptable rates of procedure-related morbidity and satisfactory rates of overall good neurological outcome.


Assuntos
Procedimentos Endovasculares/efeitos adversos , Aneurisma Intracraniano/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Aneurisma Intracraniano/mortalidade , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Adulto Jovem
9.
World Neurosurg ; 89: 108-11, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-26852711

RESUMO

BACKGROUND: Shunt infections are a major complication following ventricular shunts in adults that lead to increased heath care costs, patient morbidity, and mortality. Methods to decrease shunt infection include antibiotic-impregnated catheters, protocol-based surgery, and shunt reservoir antibiotic injection. METHODS: An Institutional Review Board-approved retrospective review was performed for all adult shunt surgeries performed from January 2000 to September 2013 at a single academic institution. Records were cross-indexed with hospital billing records to identify patients who received antibiotic injections and cross-referenced with a prospective infection control database of all surgical site infections. The primary outcome measure was shunt infection within 1 year of surgery. RESULTS: Five-hundred thirteen adult patients met inclusion criteria. Antibiotic reservoir injection was associated with a significantly lower rate of infection (2.6%) when compared with no injection (6.3%, P = 0.0455). The antibiotic injection group also included significantly more patients with infection risk factors than the control group (38.8% vs. 18.0%, P < 0.005). CONCLUSION: Antibiotic reservoir injection is an effective method of reducing shunt infections in adults when combined with standard infection control measures.


Assuntos
Antibacterianos/administração & dosagem , Derivações do Líquido Cefalorraquidiano/efeitos adversos , Infecções Relacionadas à Prótese/prevenção & controle , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Infecções Relacionadas à Prótese/microbiologia , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Adulto Jovem
10.
World Neurosurg ; 84(6): 1598-604, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26187112

RESUMO

BACKGROUND: Labeled the "obesity paradox," obesity has been shown to provide a survival advantage in coronary artery disease, stroke, and intracerebral hemorrhage. Studies on body mass index (BMI) in aneurysmal subarachnoid hemorrhage (SAH) show conflicting results and none examined a North American population with long-term follow-up. METHODS: A total of 305 consecutive SAH patients (2002 to 2011) were retrospectively reviewed to collect demographics, BMI (kg/m(2)), comorbidities, Glascow Coma Scale, World Federation of Neurologic Surgeons Scale, aneurysm treatment, delayed cerebral ischemia, radiographic infarction, and short-term and long-term (> 24 months) morbidity, and mortality. Patients were stratified by BMI into category 1, < 25 kg/m(2); category 2, 25 -< 30 kg/m(2); and category 3, ≥ 30 kg/m(2). RESULTS: Categories 1, 2, and 3 had 93, 100, and 87 patients with mean BMIs of 22.4 ± 1.8, 27.6 ± 1.4, and 35.7 ± 4.6 (P < 0.05), respectively. By category, 24-month follow-up was available in 92%, 85%, and 85%. Category 3 had more hypertension, diabetes mellitus, and clipping than category 1. Short-term mortality rates were 17%, 12%, and 8%; long-term mortality rates were 34%, 26%, and 19% (P > 0.05 at all points between categories 1 vs. 3, but not 1 vs. 2 or 2 vs. 3). On univariate analysis, BMI was inversely associated with short-term (odds ratio, 0.91; 95% confidence interval 0.84-0.98; P = 0.009) and long-term (odds ratio, 0.92; 95% confidence interval 0.87-0.97; P = 0.001) mortality. On multivariate analysis including age, World Federation of Neurologic Surgeons Scale, delayed cerebral ischemia, and radiographic infarction, BMI remained significant for short-term (odds ratio, 0.91; 95% confidence interval 0.81-0.99; P = 0.047) and long-term (odds ratio, 0.92; 95% confidence interval 0.85-0.98; P = 0.021) mortality. On Kaplan-Meier survival analysis, P > 0.05 for categories 1 versus 2 and 2 versus 3, but P = 0.005 for categories 1 versus 3. CONCLUSIONS: In our SAH population, higher BMI resulted in less short-term and long-term mortality, but no difference in functional outcome.


Assuntos
Índice de Massa Corporal , Aneurisma Intracraniano/complicações , Obesidade/complicações , Hemorragia Subaracnóidea/etiologia , Hemorragia Subaracnóidea/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , América do Norte/epidemiologia , Razão de Chances , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Hemorragia Subaracnóidea/fisiopatologia , Hemorragia Subaracnóidea/terapia , Resultado do Tratamento
11.
Childs Nerv Syst ; 31(8): 1387-92, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-25948046

RESUMO

INTRODUCTION: Pediatric pituitary neoplasms and associated pituitary apoplexy are uncommon. There are few reports in pediatric patients of pituitary apoplexy causing focal arterial compression or diffuse vasospasm resulting in cerebral infarction, and the acute, focal neurological deficits associated with stroke differ from the typical presentation of an apoplectic pituitary tumor. We report the first case of a teenage female with an apoplectic macroprolactinoma presenting with stuttering cerebral infarction secondary to compression of the internal carotid artery (ICA). CASE: A 14-year-old female was transferred from an outside facility after presenting with right hand paresthesias and word-finding difficulty that eventually progressed to include right upper extremity weakness and mental status changes. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed an apoplectic macroprolactinemia and diffusion-weighted imaging showed acute stroke in the left anterior and middle cerebral artery distributions. Evaluation of the cerebral vasculature with MRA showed focal compression of the left supraclinoid ICA. Despite prompt surgical decompression, the patient developed right lower extremity weakness in addition to her other deficits though her deficits improved after inpatient rehabilitation. CONCLUSIONS: In the pediatric population, there is only one other case of pituitary apoplexy presenting with stroke, which was secondary to vasospasm. We present the first case of pituitary apoplexy presenting with stroke secondary to ICA compression. Though rare, it is important to consider that pituitary apoplexy may present with non-classical symptoms such as ischemic stroke even in pediatric patients.


Assuntos
Neoplasias Hipofisárias/complicações , Prolactinoma/complicações , Acidente Vascular Cerebral/etiologia , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Imagem por Ressonância Magnética , Masculino , Tomógrafos Computadorizados
12.
J Neurointerv Surg ; 7(9): 646-51, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25082803

RESUMO

OBJECT: Flow diversion has emerged as a promising treatment alternative for cerebral aneurysms. As a new device, treatment-related events and complications are currently being characterized. METHODS: Data on 100 consecutive procedures with the intention to use flow diversion were prospectively collected and analyzed retrospectively. RESULTS: Ninety-five aneurysms were treated in 93 patients during 100 consecutive procedures in which the intention was to treat an intracranial aneurysm with flow diversion. Death occurred in 1% and permanent morbidity in 1%. However, periprocedural technical complications occurred in 35% of the procedures and included proximal device migration in 12%, incomplete device expansion in 9%, catheter-induced vasospasm in 6%, and artery perforation from the wire in 3%. Perioperative clinical events were seen in 28% (thromboembolism and access site complications were the most common, being observed in 6.5% of patients). Worsened extraocular motility was seen in 5.4% and resolved in 4/5 patients. Mean clinical follow-up was 17 months. There were no late clinical or technical issues resulting in permanent deficits, although one patient suffered worsening ataxia. Overall, using very strict angiographic criteria, complete angiographic obliteration was 50% at 6 months and 69% after 1 year. CONCLUSIONS: Flow diversion for intracranial aneurysms is a safe and effective treatment. Technical and clinical events are common in the perioperative period. Careful perioperative care and proper management of technical and clinical events encountered is key to achieving low morbidity and mortality. Late clinical events can occur but are unlikely to result in permanent complications.


Assuntos
Implante de Prótese Vascular/efeitos adversos , Aneurisma Intracraniano/cirurgia , Stents , Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/métodos , Angiografia Cerebral , Feminino , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Falha de Prótese/efeitos adversos , Stents/efeitos adversos , Tomografia Computadorizada por Raios X
15.
J Clin Neurosci ; 21(6): 1054-6, 2014 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-24291475

RESUMO

Distal median neuropathy from carpal tunnel syndrome is the most well known lesion affecting the median nerve. Mass lesions may affect the nerve at the wrist. We present to our knowledge the first histologically confirmed case of an intraneural fibroma.


Assuntos
Síndrome do Túnel Carpal/diagnóstico , Fibroma/diagnóstico , Nervo Mediano/patologia , Punho/patologia , Adulto , Síndrome do Túnel Carpal/etiologia , Síndrome do Túnel Carpal/cirurgia , Fibroma/complicações , Fibroma/cirurgia , Humanos , Masculino , Nervo Mediano/cirurgia , Punho/inervação , Punho/cirurgia
18.
J Neurointerv Surg ; 5(6): e47, 2013 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-23188788

RESUMO

Pediatric patients with aneurysm often have different localizations and morphologies from adults and recurrences are not uncommon after successful clip reconstruction/obliteration. Treatment of a recurrent pediatric aneurysm after clip ligation is a technical challenge. We present the case of an adolescent with a middle cerebral artery (MCA) fusiform aneurysm which recurred following clip reconstruction and bypass. The aneurysm was successfully treated with endovascular flow diversion.


Assuntos
Embolização Terapêutica/métodos , Aneurisma Intracraniano/terapia , Artéria Cerebral Média , Stents , Adolescente , Angiografia Digital , Artérias Carótidas/patologia , Cateterismo , Angiografia Cerebral , Seguimentos , Humanos , Angiografia por Ressonância Magnética , Masculino , Inibidores da Agregação de Plaquetas/uso terapêutico , Recidiva , Convulsões/etiologia , Instrumentos Cirúrgicos
19.
BMJ Case Rep ; 20122012 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-23162037

RESUMO

Pediatric patients with aneurysm often have different localizations and morphologies from adults and recurrences are not uncommon after successful clip reconstruction/obliteration. Treatment of a recurrent pediatric aneurysm after clip ligation is a technical challenge. We present the case of an adolescent with a middle cerebral artery (MCA) fusiform aneurysm which recurred following clip reconstruction and bypass. The aneurysm was successfully treated with endovascular flow diversion.


Assuntos
Embolização Terapêutica/instrumentação , Aneurisma Intracraniano/terapia , Adolescente , Aspirina/uso terapêutico , Angiografia Cerebral , Clopidogrel , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/tratamento farmacológico , Masculino , Inibidores da Agregação de Plaquetas/uso terapêutico , Recidiva , Ticlopidina/análogos & derivados , Ticlopidina/uso terapêutico
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