RESUMEN
The authors present a case of a patient with a Barrow Type B carotid-cavernous fistula (CCF) who presented with severe symptoms of eye redness, diplopia, and proptosis. Due to the tortuosity and size of her angular vein and the lack of good flow/access via the inferior petrosal sinus, she was treated with a transvenous approach via a large, dilated superior ophthalmic vein for coil embolization of the CCF. The patient had a full angiographic and symptomatic cure. The authors present the treatment plan and strategy and the fluoroscopic recording of the treatment. Nuances of the technique are discussed.The video can be found here: https://youtu.be/ABkGm17-cBU.
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Fístula del Seno Cavernoso de la Carótida/cirugía , Seno Cavernoso/cirugía , Venas/cirugía , Embolización Terapéutica/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
PURPOSE: Cerebellar glioblastomas in children are rare. As a result, an optimal treatment strategy has not yet been identified. A review of the characteristics of the disease as well as the effectiveness of various therapeutic modalities would help in optimizing the treatment paradigm. METHODS: We performed a detailed clinical, radiographic, and pathologic retrospective review of five patients (three boys and two girls, average age at presentation 7.2 years (range, 3-14 years)) and surveyed the literature for an additional 55 cases. RESULTS: Computed tomography and magnetic resonance imaging usually revealed a large lesion with minimal edema, heterogeneous contrast enhancement, and a discrete border. Subtotal tumor resection was performed in two patients and gross total resection in three patients. Immunostaining of the tumor cells with antisera to glial fibrillary acidic protein and vimentin was variably positive. Adjuvant therapy included local radiation and chemotherapy in all followed patients. Tumor recurrence was seen in two patients. Patients were followed from 2 months to 3.5 years (mean, 12 months). Two patients were dead at last follow-up with a mean survival of 9.5 months. CONCLUSIONS: The prognosis for pediatric patients with cerebellar glioblastomas is dismal, even when compared to adult counterparts or other malignant posterior fossa tumors in children. Cerebellar glioblastomas have a tendency to recur and disseminate despite treatment with surgery, chemotherapy, and radiation. The poor outcomes seen with this tumor suggest that the optimal treatment strategy has yet to be elucidated and much work needs to be done.
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Neoplasias Cerebelosas/patología , Glioblastoma/patología , Procedimientos Neuroquirúrgicos/métodos , Adolescente , Neoplasias Cerebelosas/tratamiento farmacológico , Neoplasias Cerebelosas/radioterapia , Niño , Preescolar , Terapia Combinada , Resultado Fatal , Femenino , Estudios de Seguimiento , Glioblastoma/tratamiento farmacológico , Glioblastoma/radioterapia , Humanos , Imagen por Resonancia Magnética , Masculino , Recurrencia Local de Neoplasia/patología , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
Patients suffering from disorders of consciousness constitute a population that exists largely outside of the daily practice patterns of neurosurgeons. Historically, treatment has focused on nursing and custodial issues with limited neurosurgical intervention. Recently, however, deep brain stimulation has been explored to restore cognitive and physical function to patients in minimally conscious states. In this article, the authors characterize the physiological mechanisms for the use of deep brain stimulation in persistently vegetative and minimally conscious patients, review published cases and associated ethical concerns, and discuss future directions of this technology.
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Trastornos de la Conciencia/terapia , Estimulación Encefálica Profunda/métodos , Corteza Cerebral/fisiología , Estimulación Encefálica Profunda/ética , Humanos , Vías Nerviosas/fisiología , Estado Vegetativo Persistente/terapia , Formación Reticular/fisiología , Tálamo/fisiología , Resultado del TratamientoRESUMEN
BACKGROUND: Intraoperative computed tomography angiography (ICTA) is a novel completion imaging modality for carotid endarterectomy (CEA). No studies exist in the literature describing ICTA use in CEA. OBJECTIVE: To evaluate the feasibility and efficacy of ICTA as a method of immediately evaluating the technical results of CEA. METHODS: Twenty-three consecutive CEAs were performed by a single neurosurgeon over an 8-month period. Of this series, 12 utilized ICTA for completion imaging, 10 utilized duplex ultrasonography (US), and 1 utilized no intraoperative completion imaging. Electronic medical records were reviewed to assess demographics, CTA results, US results, and need for revisions. RESULTS: Patients included 13 men (62%) and 8 women (38%). All patients had symptomatic internal carotid artery stenosis. Polytetrafluoroethylene (PTFE) patch angioplasty was used in 16 cases (70%). Average operative times were comparable between cases that utilized CTA and US, 180 and 175 min, respectively. Major technical defects were identified in one of the 12 cases utilizing ICTA and none of the 10 cases utilizing intraoperative US. The technical defect was revised without subsequent neurological complication. One patient had a postoperative intracerebral hemorrhage requiring surgical evacuation. Fifteen patients were followed for up to 3 months with no postoperative stroke or transient ischemic attacks. CONCLUSION: ICTA is a potentially safe and effective completion imaging modality compared to traditional alternatives, enabling the identification of technical deficits intraoperatively. While no statistically significant difference in operative times were noted between intraoperative CTA and US use, numerous steps must be taken to maximize the efficiency of ICTA.
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Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/cirugía , Angiografía por Tomografía Computarizada , Endarterectomía Carotidea/métodos , Monitoreo Intraoperatorio/métodos , Anciano , Angiografía de Substracción Digital , Femenino , Humanos , Angiografía por Resonancia Magnética , Masculino , Persona de Mediana Edad , Monitoreo Intraoperatorio/instrumentaciónRESUMEN
BACKGROUND: Pseudoaneurysms of scalp arteries have been reported in rare cases after iatrogenic injury; however, they are far more commonly seen after traumatic injuries. They are usually associated with the superficial temporal artery; however, there have been a few reports of psuedoaneurysms of the occipital artery (OA). CASE DESCRIPTION: We present a unique case of an OA pseudoaneurysm presenting with delayed postoperative hemorrhage after a retrosigmoid craniotomy. The pseudoaneurysm was treated by coil embolization. CONCLUSIONS: The patient recovered fully after endovascular embolization. Other treatment options for pseudoaneurysms of facial, temporal, and scalp arteries include surgical clipping/trapping with excision, Hunterian ligation, or direct compression. Pseudoaneurysms of extracranial scalp arteries are rare and most often caused by traumatic compression of the artery against a bony ridge. Despite their rarity, pseudoaneurysms secondary to iatrogenic injury to extracranial arteries should be considered in the differential diagnosis in patients presenting with delayed incisional pain, redness, and swelling.
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Aneurisma Falso/etiología , Enfermedades Arteriales Cerebrales/etiología , Craneotomía/efectos adversos , Aneurisma Falso/cirugía , Enfermedades Arteriales Cerebrales/cirugía , Embolización Terapéutica/métodos , Procedimientos Endovasculares/métodos , Humanos , Persona de Mediana Edad , Lóbulo Occipital/irrigación sanguínea , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugíaRESUMEN
Near-infrared spectroscopy (NIRS) is a technique by which the interaction between light in the near-infrared spectrum and matter can be quantitatively measured to provide information about the particular chromophore. Study into the clinical application of NIRS for traumatic brain injury (TBI) began in the 1990s with early reports of the ability to detect intracranial hematomas using NIRS. We highlight the advances in clinical applications of NIRS over the past two decades as they relate to TBI. We discuss recent studies evaluating NIRS techniques for intracranial hematoma detection, followed by the clinical application of NIRS in intracranial pressure and brain oxygenation measurement, and conclude with a summary of potential future uses of NIRS in TBI patient management.
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BACKGROUND: Primary intraosseous calvarial hemangiomas (PICHs) are generally rare and predominate (3:1) in women. Occurrence in the frontal and parietal bones is most common, but involvement of the occipital bone is exceedingly rare, representing 3 of 125 cases in a series of PICHs studied by Heckl et al. in 2000. Histopathology establishes the diagnosis of cavernous hemangioma, which represents the most common subtype of intraosseous hemangiomas. Others include sclerosing, cellular, and capillary. When they do occur in the calvarium, they are most often asymptomatic and discovered incidentally or due to a palpable defect in the skull. CASE DESCRIPTION: In this case, a calvarial hemangioma was found to be the cause of elevated intracranial pressure in a 35-year-old woman. Resection of the hemangioma and reconstruction of the calvarium provided a complete cure for her symptoms. CONCLUSIONS: Primary intraosseous hemangiomas are rarely symptomatic but must be considered in the differential for calvarial lesions as part of safe surgical planning. Formulating an accurate differential diagnosis by acquiring proper imaging studies and specifically recognizing the classical "starburst" appearance, as well as considering the highly vascular pathology to avoid excess blood loss, is important. This unique case of a hemangioma-induced venous sinus compression and subsequent elevated intracranial pressure illustrates that hemangiomas can arise from any part of the calvarium and cause a wide variety of clinical symptoms.
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Hemangioma Cavernoso/complicaciones , Hemangioma Cavernoso/cirugía , Hipertensión Intracraneal/etiología , Hueso Occipital/patología , Neoplasias Craneales/complicaciones , Neoplasias Craneales/cirugía , Adulto , Femenino , Hemangioma Cavernoso/diagnóstico por imagen , Humanos , Hipertensión Intracraneal/diagnóstico por imagen , Hipertensión Intracraneal/cirugía , Angiografía por Resonancia Magnética , Imagen por Resonancia Magnética , Obesidad/complicaciones , Hueso Occipital/diagnóstico por imagen , Neoplasias Craneales/diagnóstico por imagen , Tomógrafos Computarizados por Rayos XRESUMEN
UNLABELLED: OBJECT.: There are rare indications for upper cervical spine fusion in young children. Compared with nonrigid constructs, rigid instrumentation with screw fixation increases the fusion rate and reduces the need for halo fixation. Instrumentation may be technically challenging in younger children. A number of screw placement techniques have been described. Use of C-2 translaminar screws has been shown to be anatomically feasible, even in the youngest of children. However, there are few data detailing the clinical outcome. In this study, the authors describe the clinical and radiographic follow-up of 18 children 5 years of age or younger who had at least one C-2 translaminar screw as part of an occipitocervical or C1-2 fusion construct. METHODS: A retrospective review of all children treated with instrumented occipitocervical or C1-2 fusion between July 1, 2007, and June 30, 2013, at Riley Children's Hospital and Texas Children's Hospital was performed. All children 5 years of age or younger with incorporation of at least one C-2 translaminar screw were identified. RESULTS: Eighteen children were studied (7 boys and 11 girls). The mean age at surgery was 38.1 months (range 10-68 months). Indications for surgery included traumatic instability (6), os odontoideum (3), destructive processes (2), and congenital instability (7). A total of 24 C-2 translaminar screws were placed; 23 (95.8%) of 24 were satisfactorily placed (completely contained within the cortical walls). There was one medial cortex breach without neurological impingement. There were no complications with screw placement. Three patients required wound revisions. Two patients died as a result of their original condition (trauma, malignant tumor). The mean follow-up duration for the surviving patients was 17.5 months (range 3-60 months). Eleven (91.7%) of the 12 patients followed for 6 months or longer showed radiographic stability or completed fusion. CONCLUSIONS: Use of C-2 translaminar screws provides an effective anchor for internal fixation of the upper cervical spine. In this study of children 5 years of age or younger, the authors found a high rate of radiographic fusion with a low rate of complications.
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Proteína Morfogenética Ósea 2/uso terapéutico , Tornillos Óseos , Vértebras Cervicales/cirugía , Fijación Interna de Fracturas/métodos , Hueso Occipital/cirugía , Fusión Vertebral/instrumentación , Fusión Vertebral/métodos , Vértebras Cervicales/diagnóstico por imagen , Preescolar , Estudios de Factibilidad , Femenino , Humanos , Indiana , Masculino , Hueso Occipital/diagnóstico por imagen , Radiografía , Reoperación , Estudios Retrospectivos , Fusión Vertebral/efectos adversos , Texas , Resultado del Tratamiento , Cicatrización de HeridasRESUMEN
OBJECT: Upper cervical spine injuries in the pediatric age group have been recognized as extremely unstable from ligamentous disruption and as potentially lethal. Few measurement norms have been published for the pediatric upper cervical spine to help diagnose this pathological state. Instead, adult measurement techniques and results are usually applied inappropriately to children. The authors propose using high-resolution reconstructed CT scans to define a range of normal for a collection of selected upper cervical spine measurements in the pediatric age group. METHODS: Sagittal and coronal reformatted images were obtained from thin axial CT scans obtained in 42 children (< 18 years) in a 2-month period. There were 25 boys and 17 girls. The mean age was 100.9 months (range 1-214 months). Six CT scans were obtained for nontrauma indications, and 36 were obtained as part of a trauma protocol and later cleared for cervical spine injury. Six straightforward and direct linear distances-basion-dental interval (BDI); atlantodental interval (ADI); posterior atlantodental interval (PADI); right and left lateral mass interval (LMI); right and left craniocervical interval (CCI); and prevertebral soft-tissue thickness at C-2-that minimized logistical and technical distortions were measured and recorded. Statistical analysis including interobserver agreement, age stratification, and sex differences was performed for each of the 6 measurements. RESULTS: The mean ADI was 2.25 ± 0.24 mm (± SD), the mean PADI was 18.3 ± 0.07 mm, the mean BDI was 7.28 ± 0.10 mm, and the mean prevertebral soft tissue width at C-2 was 4.45 ± 0.43 mm. The overall mean CCI was 2.38 ± 0.44 mm, and the overall mean LMI was 2.91 ± 0.49 mm. Linear regression analysis demonstrated statistically significant age effects for PADI (increased 0.02 mm/month), BDI (decreased 0.02 mm/month), and CCI (decreased 0.01 mm/month). Similarly significant effects were found for sex; females demonstrated on average a smaller CCI by 0.26 mm and a smaller PADI by 2.12 mm. Moderate to high interrater reliability was demonstrated across all parameters. CONCLUSIONS: Age-dependent and age-independent normal CT measurements of the upper cervical spine will help to differentiate physiological and pathological states in children. The BDI appears to change significantly with age but not sex; on the other hand, the LMI and ADI appear to be age-independent measures. This preliminary study suggests acceptable levels of interrater reliability, and further expanded study will aim to validate these measurements to produce a profile of normal upper cervical spine measurements in children.
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Médula Espinal/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Adolescente , Factores de Edad , Vértebras Cervicales/lesiones , Niño , Preescolar , Femenino , Humanos , Lactante , Modelos Lineales , Masculino , Variaciones Dependientes del Observador , Valores de Referencia , Reproducibilidad de los Resultados , Factores Sexuales , Traumatismos Vertebrales/diagnóstico por imagenRESUMEN
OBJECTIVE: To compare outcomes in the setting of spontaneous intracerebral hemorrhage (ICH) in patients taking aspirin (acetylsalicylic acid [ASA]) versus patients taking clopidogrel before hospitalization. METHODS: Patients admitted to the neurosurgical service with a spontaneous ICH while taking an antiplatelet agent were prospectively identified and retrospectively reviewed. Two groups of 28 consecutive patients taking ASA or clopidogrel on admission were ultimately evaluated. RESULTS: Patients in the clopidogrel group had a mean age of 72.6 years, and patients in the ASA group had a mean age of 65.8 years (P=0.04). Patients taking clopidogrel before hospitalization were significantly more likely than patients taking ASA to experience an increase in hematoma volume (P=0.05). Patients in the ASA group trended toward being discharged to home more frequently than other destinations (P=0.07). The in-hospital mortality rates in this series were 14.3% for the ASA group and 28.6% for the clopidogrel group. However, this association did not reach statistical significance (P=0.19). CONCLUSIONS: In this study, patients taking clopidogrel showed more hematoma expansion, higher in-hospital mortality rates, and a decreased likelihood of a home discharge compared with patients taking ASA alone.