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Klinger DR, Dillon RL, Clement NF, Cloran FJ, Horkayne-Szakaly I. Intradural extramedullary pleomorphic xanthoastrocytoma: A case report. Surg Neurol Int 2020; 11:368. [PMID: 33194301 PMCID: PMC7656036 DOI: 10.25259/sni_682_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 10/07/2020] [Indexed: 11/05/2022] Open
Abstract
Background: Pleomorphic xanthoastrocytomas (PXAs) are uncommon intradural and typically intramedullary astrocytic central nervous system tumors. Although they commonly occur supratentorially, they are rarely seen in the spine. Case Description: A 43-year-old male presented with cervical neck pain and right-sided radicular symptoms. He was found to have an intradural extramedullary mass at the C5–C6 level. The lesion was fully excised and proved to be a PXA. Of interest, the lesion did not recur on postoperative MR imaging studies obtained 7 months later. Conclusion: While rare, primary intradural extramedullary spinal PXA has been reported. Here, we review such a lesion occurring in a 43-year-old male who did well following gross total excision of the tumor.
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Affiliation(s)
- Daniel R Klinger
- Department of Neurosurgery, Brooke Army Medical Center, Roger Brooke Drive, Fort Sam Houston, San Antonio, Texas, United States
| | - Rebecca L Dillon
- Department of Radiology Brooke Army Medical Center, Roger Brooke Drive, Fort Sam Houston, San Antonio, Texas, United States
| | - Nathan F Clement
- Department of Pathology, Brooke Army Medical Center, Roger Brooke Drive, Fort Sam Houston, San Antonio, Texas, United States
| | - Francis J Cloran
- Department of Radiology Brooke Army Medical Center, Roger Brooke Drive, Fort Sam Houston, San Antonio, Texas, United States
| | - Iren Horkayne-Szakaly
- Department of Neuropathology and Ophthalmic Pathology, The Joint Pathology Center, Silver Spring, Maryland, United States
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Klinger DR, Reinard KA, Ajayi OO, Delashaw JB. Microsurgical Clipping of an Anterior Communicating Artery Aneurysm Using a Novel Robotic Visualization Tool in Lieu of the Binocular Operating Microscope: Operative Video. Oper Neurosurg (Hagerstown) 2019; 14:26-28. [PMID: 29253287 DOI: 10.1093/ons/opx081] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 03/16/2017] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The binocular operating microscope has been the visualization instrument of choice for microsurgical clipping of intracranial aneurysms for many decades. OBJECTIVE To discuss recent technological advances that have provided novel visualization tools, which may prove to be superior to the binocular operating microscope in many regards. METHODS We present an operative video and our operative experience with the BrightMatterTM Servo System (Synaptive Medical, Toronto, Ontario, Canada) during the microsurgical clipping of an anterior communicating artery aneurysm. To the best of our knowledge, the use of this device for the microsurgical clipping of an intracranial aneurysm has never been described in the literature. RESULTS The BrightMatterTM Servo System (Synaptive Medical) is a surgical exoscope which avoids many of the ergonomic constraints of the binocular operating microscope, but is associated with a steep learning curve. The BrightMatterTM Servo System (Synaptive Medical) is a maneuverable surgical exoscope that is positioned with a directional aiming device and a surgeon-controlled foot pedal. While utilizing this device comes with a steep learning curve typical of any new technology, the BrightMatterTM Servo System (Synaptive Medical) has several advantages over the conventional surgical microscope, which include a relatively unobstructed surgical field, provision of high-definition images, and visualization of difficult angles/trajectories. CONCLUSION This device can easily be utilized as a visualization tool for a variety of cranial and spinal procedures in lieu of the binocular operating microscope. We anticipate that this technology will soon become an integral part of the neurosurgeon's armamentarium.
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Affiliation(s)
- Daniel R Klinger
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, Washington
| | - Kevin A Reinard
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, Washington
| | - Olaide O Ajayi
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, Washington.,Department of Neurosurgery, Loma Linda University Medical Center, Loma Linda, California
| | - Johnny B Delashaw
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, Washington
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Klinger DR, Reinard KA, Ajayi OO, Delashaw JB. In Reply: Microsurgical Clipping of an Anterior Communicating Artery Aneurysm Using a Novel Robotic Visualization Tool in Lieu of the Binocular Operating Microscope: Operative Video. Oper Neurosurg (Hagerstown) 2018; 15:E29. [PMID: 29878252 DOI: 10.1093/ons/opy081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Daniel R Klinger
- Department of Neurosurgery Swedish Neuroscience Institute Seattle, Washington
| | - Kevin A Reinard
- Department of Neurosurgery Swedish Neuroscience Institute Seattle, Washington
| | - Olaide O Ajayi
- Department of Neurosurgery Swedish Neuroscience Institute Seattle, Washington.,Department of Neurosurgery Loma Linda University Medical Center Loma Linda, California
| | - Johnny B Delashaw
- Department of Neurosurgery Swedish Neuroscience Institute Seattle, Washington
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Flores BC, Klinger DR, White JA, Batjer HH. Spinal vascular malformations: treatment strategies and outcome. Neurosurg Rev 2016; 40:15-28. [DOI: 10.1007/s10143-016-0713-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 11/05/2015] [Accepted: 01/25/2016] [Indexed: 12/16/2022]
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Klinger DR, White JA, Batjer HH. Race and Hemorrhage in Cerebral Arteriovenous Malformations. World Neurosurg 2015; 84:640-2. [PMID: 25980598 DOI: 10.1016/j.wneu.2015.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 05/07/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Daniel R Klinger
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
| | - Jonathan A White
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - H Hunt Batjer
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Flores BC, Klinger DR, Rickert KL, Barnett SL, Welch BG, White JA, Batjer HH, Samson DS. Management of intracranial aneurysms associated with arteriovenous malformations. Neurosurg Focus 2014; 37:E11. [DOI: 10.3171/2014.6.focus14165] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intracranial or brain arteriovenous malformations (BAVMs) are some of the most interesting and challenging lesions treated by the cerebrovascular neurosurgeon. It is generally believed that the combination of BAVMs and intracranial aneurysms (IAs) is associated with higher hemorrhage rates at presentation and higher rehemorrhage rates and thus with a more aggressive course and natural history. There is wide variation in the literature on the prevalence of BAVM-associated aneurysms (range 2.7%–58%), with 10%–20% being most often cited in the largest case series. The risk of intracranial hemorrhage in patients with unruptured BAVMs and coexisting IAs has been reported to be 7% annually, compared with 2%–4% annually for those with BAVM alone. Several different classification systems have been applied in an attempt to better understand the natural history of this combination of lesions and implications for treatment. Independent of the classification used, it is clear that a few subtypes of aneurysms have a direct hemodynamic correlation with the BAVM itself. This is exemplified by the fact that the presence of a distal flow-related or an intranidal aneurysm appears to be associated with an increased hemorrhage risk, when compared with an aneurysm located on a vessel with no direct supply to the BAVM nidus. Debate still exists regarding the etiology of the association between those two vascular lesions, the subsequent implications for patients’ risk of hemorrhagic stroke, and finally the determination of which patients warrant treatment and when. The ultimate goals of the treatment of a BAVM associated with an IA are to prevent hemorrhage, avoid stepwise neurological deterioration, and eliminate the mortality risk associated with recurrent hemorrhagic events. The treatment is only justifiable if the risks associated with an intervention are lower than or equivalent to the long-term risks of disability or mortality caused by the lesion itself. When faced with this difficult decision, a few questions need to be answered by the treating neu-rosurgeon: What is the mode of presentation? What is the symptomatic lesion? Which one of the lesions bled? What is the relationship between the BAVM and IA? Is it possible to safely treat both BAVM and IA? The objective of this review is to discuss the demographics, natural history, classification, and strategies for management of BAVMs associated with IAs.
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Affiliation(s)
- Bruno C. Flores
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Daniel R. Klinger
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kim l. Rickert
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
- 2 Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Samuel l. Barnett
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Babu G. Welch
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
- 2 Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jonathan A. White
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
- 2 Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - H. Hunt Batjer
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Duke S. Samson
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
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Abstract
Cavernous sinus meningiomas (CSMs) are challenging lesions for the skull base neurosurgeon to manage given their close association with cranial nerves II-VI and the internal carotid artery. In the 1980s and early 1990s, with advancements in microsurgical techniques, increasing knowledge of the relevant microsurgical neuroanatomy, and the advent of advanced skull base surgical approaches, the treatment of CSMs involved attempts at gross-total resection (GTR). Initial fervor for a surgical cure waned, however, as skull base neurosurgeons demonstrated the limits of complete resection in this region, the ongoing issue of potential tumor recurrences, and the unacceptably high cranial nerve and vascular morbidity associated with this strategy. The advent of radiosurgery and its documented success for tumor growth control and limited morbidity in cavernous lesions has helped to shift the treatment goals for CSMs from GTR to tumor control and symptom relief while minimizing treatment- and lesion-associated morbidity. The authors review the relevant microanatomy of the cavernous sinus with anatomical and radiographic correlates, as well as the various treatment options. A modernized, multimodality treatment algorithm to guide management of these lesions is proposed.
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Affiliation(s)
- Daniel R Klinger
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
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Ray B, Rickert KL, Welch BG, White JA, Klinger DR, Boudreaux BP, Whittemore BA, Gu E. Development of contrast-induced nephropathy in subarachnoid hemorrhage: a single center perspective. Neurocrit Care 2014; 19:150-6. [PMID: 23653268 DOI: 10.1007/s12028-013-9850-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND PURPOSE The use of iodinated contrast-enhanced imaging studies is increasing in acute cerebrovascular diseases, especially in subarachnoid hemorrhage (SAH). In SAH, such studies are essential for both diagnosis and treatment of the cause and sequela of hemorrhage. These patients are often subjected to multiple contrast studies such as computed tomographic angiography, computed tomographic perfusion, and cerebral angiography. They are also predisposed to intravascular volume depletion as a part of the disease process from cerebral salt wasting (CSW) and as a result of multiple contrast exposure can develop contrast-induced nephropathy (CIN). Data regarding CIN in this population are scarce. We aimed to examine the incidence of CIN in SAH and identify potential associative risk factors. METHODS We analyzed data from a prospectively collected patient database of patients with SAH admitted to the neurocritical intensive care unit in a single center over a period of 1 year. CIN was defined as an increase in serum creatinine by >1.5 times or >0.3 mg/dl greater than the admission value, or urine output <0.5 ml/kg/h during one 6-h block. RESULTS In this cohort of 75 patients with SAH who had undergone at least one contrast study, the mean age was 57.3 ± 15.6 years and 70.7% were women. Four percent developed CIN which resolved within 72 h and none required renal replacement therapy or dialysis. Patients older than 75 years (20%, p < 0.05), those with borderline renal function (14.3%, p = 0.26), diabetics (11.1%, p = 0.32), and those with lower recommended "maximum contrast dose" volume (33.3%, p = 0.12) had a trend toward development of CIN, although most were not statistically significant. Twenty-seven patients (36 %) were on 3% hypertonic saline (HTS) for CSW during the contrasted study but none developed CIN. CONCLUSIONS The incidence of CIN in SAH patients is comparable to previously published reports on non-neurological cohorts. No definite association was noted with any predisposing factors postulated to be responsible for CIN, except for advanced age. Concurrent use of 3% HTS was not associated with CIN in this population.
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Affiliation(s)
- Bappaditya Ray
- Division of Neurocritical Care, Department of Neurological Surgery and Neurology & Neurotherapeutics, University of Texas-Southwestern Medical Center, Dallas, TX, USA,
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Abstract
Foramen magnum meningiomas (FMMs) are slow growing, most often intradural and extramedullary tumors that pose significant challenges to the skull base neurosurgeon. The indolent clinical course of FMMs and their insidious onset of symptoms are important factors that contribute to delayed diagnosis and relative large size at the time of presentation. Symptoms are often produced by compression of surrounding structures (such as the medulla oblongata, upper cervical spinal cord, lower cranial nerves, and vertebral artery) within a critically confined space. Since the initial pathological description of a FMM in 1872, various surgical approaches have been described with the aim of achieving radical tumor resection. The surgical treatment of FMMs has evolved considerably over the last 4 decades due to the progress in microsurgical techniques and development of a multitude of skull base approaches. Posterior and posterolateral FMMs can be safely resected via a standard midline suboccipital approach. However, controversy still exits regarding the optimal management of anterior or anterolateral lesions. Independently of technical variations and the degree of bone removal, all modern surgical approaches to the lower clivus and anterior foramen magnum derive from the posterolateral (or far-lateral) craniotomy originally described by Roberto Heros and Bernard George. This paper is a review of the surgical management of FMMs, with emphasis on the far-lateral approach and its variations. Clinical presentation, imaging findings, important neuroanatomical correlations, recurrence rates, and outcomes are discussed.
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Klinger DR, Harell GS, Zboralske F. Dynamic response criteria for fluid-filled esophageal manometers. Invest Radiol 1977; 12:515-9. [PMID: 591252 DOI: 10.1097/00004424-197711000-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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