Maturation of intracranial immature teratomas. Report of two cases

Immature teratomas arising within the central neuraxis are rare neoplasms. These tumors contain diverse cell lineages that retain an embryonal character and display phenotypic differentiation attributed to the three classic germ layers. The clinical management of these lesions is unclear, due in part to their low incidence and to an incomplete understanding of their natural history. Although the potential for phenotypic differentiation and cellular maturation within immature teratomas arising in the gonads is well documented, this has not been described in the intracranial tumors. In the present report, the authors describe two cases of intracranial immature teratomas, one involving the pineal region and the other involving the left frontotemporal lobes, which underwent cellular differentiation and maturation. At initial resection, the tumors from both cases were composed predominantly of primitive neuroepithelial tissue that was admixed with immature and differentiating mesenchymal and epithelial structures. No foci of germinoma, endodermal sinus, choriocarcinoma, or embryonal carcinoma tissue were present. Subsequent resections in both cases revealed an absence of immature tissue. The tumor in Case 1 contained only differentiated epithelial and mesenchymal tissue with no neuroepithelial component, whereas the tumor in Case 2 demonstrated abundant mature neuronal and glial tissue. These two cases from different intracranial sites suggest that spontaneous maturation may be a significant aspect of the natural history of intracranial immature teratomas.

Medical management in the endovascular treatment of carotid-cavernous aneurysms

Carotid-cavernous aneurysms account for between 1.9% and 9.0% of intracranial aneurysms. Entirely intercavernous aneurysms are believed to have a relatively benign course, with cranial nerve findings or headache being the usual initial symptomatology; however, subarachnoid hemorrhage or carotid-cavernous fistula formation can result from rupture. Over the past 15 years endovascular parent artery occlusion has essentially replaced surgical carotid occlusion as the treatment of choice. The authors describe a series of 39 consecutive patients at the University of Virginia Health Sciences Center who underwent endovascular treatment of a carotid-cavernous aneurysm. Aggressive invasive hemodynamic monitoring and maintenance of a state of normo- to mild hypervolemia in the asymptomatic patient was used throughout the periprocedural period. Rapid institution of hypervolemic-hypertensive therapy can reverse early neurological deficits related to hypoperfusion in these patients. Only one individual managed with this protocol developed neurological deficits not reversible with hypertensive-hypervolemic therapy. Heparin therapy was administered for 48 hours after occlusion, with patients receiving subsequent aspirin therapy for 6 months to combat distal embolism secondary to thrombosis. Long-term complications were not seen in patients receiving aneurysm trapping; however, two individuals with proximal carotid occlusion developed late optic neuropathy and one had recurrent transient ischemic attacks that ceased with supraclinoidal carotid clipping.

Surgical approaches for the correction of unstable thoracolumbar burst fractures: a retrospective analysis of treatment outcomes

The authors retrospectively studied 49 nonparaplegic patients who sustained acute unstable thoracolumbar burst fractures. All patients underwent surgical treatment and were followed for an average of 27 months. All but one patient achieved solid radiographic fusion. Three treatment groups were studied: the first group of 16 patients underwent anterior decompression and fusion with instrumentation; the second group of 27 patients underwent posterior decompression and fusion; and the third group of six patients had combined anterior-posterior surgery. Prior to surgical intervention, these groups were compared and found to be similar in age, gender, level of injury, percentage of canal compromise, neurological function, and kyphosis. Patients treated with posterior surgery had a statistically significant diminution in operative time and blood loss and number of units transfused. There were no significant intergroup differences when considering postoperative kyphotic correction, neurological function, pain assessment, or the ability to return to work. Posterior surgery was found to be as effective as anterior or anterior-posterior surgery when treating unstable thoracolumbar burst fractures. Posterior surgery, however, takes the least time, causes the least blood loss, and is the least expensive of the three procedures.

Extradural failure in glioblastoma multiforme: MRI demonstration

Glioblastoma multiforme is invariably associated with intracranial failure following conventional therapy. Extracranial as well as metastatic failure are rarely seen. Subtle extracranial abnormalities in most patients with glioblastoma multiforme are not indicative of convexity failure. However, in patients with high p53 and Ki67 immunoreactivity and in whom the dura was not closed at the time of craniotomy, the possibility of early extradural failure should be considered.

Multivariate analysis and prediction of outcome following penetrating head injury

Schemes for predicting outcome in craniocerebral missile injury have ranged from Cushing's analysis that was based on the physical characteristics of the injury to complex logistic analyses that incorporate radiographic, laboratory, and clinical data. Generation of predictive scales is discussed, focusing on the utility of the Glasgow Coma Scale (GCS) score at presentation, presence or absence of coagulopathy, and radiographic evidence of the volume and type of tissue damage.

Tumoral calcium pyrophosphate dihydrate deposition disease mimicking a cervical spine neoplasm: case report

A case of tumoral calcium pyrophosphate dihydrate crystal deposition disease involving the upper cervical spine is reported. It presented clinically, radiographically, and by preliminary intraoperative pathological evaluation as a possible malignant soft tissue tumor. An aggressive resection of the lesion was performed. This case differs from previous reports of calcium pyrophosphate dihydrate crystal deposition disease of the cervical spine by the size, location, and radiographic appearance of the lesion. We suggest that radical surgical procedures should not be performed without consideration of this diagnosis in lesions with similar presentations. A brief review of spinal and tumoral calcium pyrophosphate dihydrate crystal deposition is presented.

Neurosurgical considerations of cranial base surgery

Several craniotomies have been described that allow extensive resection of skull base and low-lying cranial tumors that involve little disfigurement to the patient. These techniques should be of interest to plastic surgeons as they may be called to aid their neurosurgical colleagues in exposing the anterior skull base or may be involved in combined procedures to resect tumors that involve the face, sinuses, orbit, and cranial vault.

Fusion with occipital bone for atlantoaxial instability: technical note

A technique is described of using autologous occipital bone for posterior atlantoaxial fusions. The advantages include the ease of harvest, the lack of postoperative discomfort, and the suitability of occipital bone for the fusion.

Surgeon's foot: a report of sural nerve palsy

Although compression neuropathies are encountered frequently in neurosurgical practice, involvement of the sural nerve is described rarely. We report a case of bilateral compression neuropathy of the sural nerve with an unusual mechanism of injury. The case is discussed, and the pertinent literature is reviewed.

Classification of civilian craniocerebral gunshot wounds: a multivariate analysis predictive of mortality

Management of cerebral gunshot injuries has changed considerably since Cushing's (1916) and Matson's (1948) classification schemes, developed during World War I and World War II, respectively. These military injuries are characterized by either very high mass, low-velocity shrapnel wounds or by high muzzle velocity missiles causing extensive destruction of tissue. The preponderance of low muzzle velocity weapons seen in clinical practice and the availability of computed tomographic (CT) evaluation within minutes after presentation has altered the range of prognostic indicators available to the neurosurgeon and the amount of relative importance placed on each factor. Raimondi and Samuelson (1970) noted this difference in wound ballistics and offered a classification scheme based on initial neurologic assessment. No well-defined classification system for civilian craniocerebral gunshot wounds has been proposed that evaluates and integrates clinical, laboratory, and neuroradiologic data. A retrospective study was performed on all 62 civilians with gunshot wounds to the head admitted to the University of Virginia Hospital between December, 1984, and November, 1990. The patient population consists of 86% males and 14% females, with an age range of 10-72 years; 60% self-inflicted wounds and 32% patients who died en route or immediately upon arrival at the hospital. The overall mortality rate was 55% at 1 week postinjury. Although we have demonstrated an association between some previously defined factors and prognosis in civilian injury, such as admission Glasgow Coma Scale (GCS) (p = 0.001) and initial pupillary response (p less than 0.001), we have also defined other significant predictors of outcome including abnormal coagulation states on admission (p less than 0.001) and the neuroradiologic examination.(ABSTRACT TRUNCATED AT 250 WORDS)

Duraplasty in cranial base resection

Complications of cerebrospinal fluid leakage following cranial base surgery are a predominant source of morbidity and mortality. The physical properties of the dura in this region, advanced patient age, previous irradiation, and the extent of tumor resection often limit or complicate the reconstructive options available to cranial base surgeons. We describe a technique that delivers vascularized tissue to the dural wound by transposing a dural flap based on the axial pedicle blood supply from the middle meningeal artery. This "duraplasty" can allow primary closure of defects at the cranial base. The donor site, which is less gravitationally dependent, more accessible, and often not affected by radiation therapy, can be closed using traditional methods. Advantages, disadvantages, and indications for this technique are discussed.

Surgical treatment of metopic synostosis

Metopic synostosis can present with various skull abnormalities for which early surgical treatment can provide significant benefit to the patient. Correction of skull deformities associated with metopic synostosis requires accurate assessment of the full range of craniofacial defects within context of the patient's age. Alteration in the characteristics of cranial bone as the child grows older necessitates modifications in techniques used for bony remodeling. Changes in the rate of brain and cranial vault growth also must be considered for adjustments in fixation methods. Thus, both the patient's age and the severity of aesthetic deformity dictate the surgical techniques used in the correction of metopic synostosis.

Gastrointestinal myoelectric and clinical patterns of recovery after laparotomy

The objective of this study was to define the patterns of myoelectric activity that occur throughout the gastrointestinal tract during normal recovery from laparotomy. Electrodes were placed on the stomach, jejunum, and transverse colon of 44 patients undergoing laparotomy. Basal electric rhythms in all areas showed no changes in frequency after operation (up to 1 month). Gastric spike wave activity showed a gradient of increasing activity from fundus to antrum. Antral spike activity was unchanged during the study. Jejunal spike activity was present in the earliest recordings and occurred in 45.9% +/- 3.5% to 59.9% +/- 5.5% of slow waves. Recovery of normal colon discrete and continuous electric response activity occurred on postoperative day 5.9 +/- 1.5. Bowel sounds returned on day 2.4 +/- 0.5 and passage of flatus and stool occurred on day 5.1 +/- 0.2. The myoelectric parameters measured are not absolutely predictive of uneventful recovery from postoperative ileus but they are, as a group, more informative than any currently available clinical criteria.

Vascular lesions involving the cranial base: combined surgical and interventional radiologic approach

Advantages and possible complications of combined surgical and interventional radiologic approach to vascular lesions involving the cranial base are presented in three case examples. The methodology and technology of endovascular embolization and occlusion techniques, selection of embolic materials, functional testing to prevent neurologic injury and surgical implications of these treatment modalities are discussed. Emphasis is placed on individualization of each combined approach relative to the aforementioned factors.

Neurosurgical applications of fibrin glue: augmentation of dural closure in 134 patients

In a wide variety of neurosurgical procedures performed on 134 patients over a 3-year period, fibrin glue has been applied as an adjunct to dural closure. Overall success at preventing cerebrospinal fluid (CSF) leakage was 90% (121 of 134, 90% effective). In patients considered to be at high risk for CSF leakage intraoperatively but without pre-established fistulae (Group 1), the success rate was higher (111 of 119, 93% effective). In patients with pre-established CSF fistulae (Group 2), the success rate was lower (10 of 15, 67% effective). As single donor sources of concentrated fibrinogen are now available with reduced risks of blood-borne disease transmission, fibrin glue may be a valuable clinical tool for the neurosurgeon.

Neurosurgical Applications of Fibrin Glue: Augmentation of Dural Closure in 134 Patients

In a wide variety of neurosurgical procedures performed on 134 patients over a 3-year period. fibrin glue has been applied as an adjunct to dural closure. Overall success at preventing cerebrospinal fluid (CSF) leakage was 90% (121 of 134, 90% effective). In patients considered to be at high risk for CSF leakage intraoperatively but without pre-established fistulae (Group 1), the success rate was higher (111 of 119, 93% effective). In patients with pre-established CSF fistulae (Group 2), the success rate was lower (10 of 15, 67% effective). As single donor sources of concentrated fibrinogen are now available with reduced risks of blood-borne disease transmission, fibrin glue may be a valuable clinical tool for the neurosurgeon. (Neurosurgery 26:207-210, 1990)