Prolactinoma extension as a contributing factor in dopamine agonist-induced CSF rhinorrhea: a systematic review of the literature

BACKGROUND

Dopamine agonist-induced cerebrospinal fluid (CSF) rhinorrhea is an uncommon treatment-related complication arising in 6.1% of prolactinoma patients treated with dopamine agonists. Locally invasive prolactinomas may create CSF fistulae through formation of dural and osseous skull base defects. Tumor shrinkage secondary to dopamine agonist therapy unmasks skull base defects, thus inducing CSF rhinorrhea. In these cases, repair of the leak may be achieved through collaborative surgical intervention by rhinologists and neurosurgeons. Multiple variables have been investigated as potential contributors to the risk of CSF rhinorrhea development in medically treated prolactinoma patients, with little consensus.

OBJECTIVE

The primary aim of our study was the characterization of risk factors for CSF rhinorrhea development following dopamine agonist treatment.

METHODS

A systematic review of the literature was conducted to identify cases of CSF rhinorrhea following dopamine agonist treatment of prolactinoma. The clinical history, radiographic findings and treatment outcomes are discussed.

RESULTS

Fifty-four patients with dopamine agonist-induced CSF rhinorrhea were identified across 23 articles published from 1979 to 2019. Description of diagnostic imaging [computed tomography (CT)/magnetic resonance imaging (MRI)] was not provided for 18/54 subjects. For the 36 cases that described prolactinoma appearance on CT or MRI, invasion of the cavernous sinuses was reported in 13 (36.1%) and invasion of the sphenoid sinus was reported in 18 (50%).

CONCLUSION

Based on our systematic review, we propose that CT findings of osseous erosion of the sella or the anterior skull base may predict dopamine agonist-induced CSF rhinorrhea. We recommend obtaining a thin-slice CT of the sinuses in cases with MRI evidence of sphenoid involvement.

Primary Dural Repair Using Titanium Microclips Following Lateral Skull Base Surgery

Objective Standard techniques for primary dural repair following lateral skull base surgery are both technically challenging and time consuming without the potential for primary dural repair. Inadequate closure may result in postoperative cerebrospinal fluid (CSF) leak infectious sequalae. Traditional methods of dural repair rely on secondary obliteration of the CSF fistula. We hypothesized that the use of nonpenetrating titanium microclips may serve as a useful adjunct in primary dural repair or the establishment of an immobile repair layer following lateral skull base surgery.

Methods Here, we report a novel technique for primary dural repair using nonpenetrating titanium microclips as an adjunct to standard techniques in a series of six patients with lateral skull base pathologies.

Results A total of six consecutive lateral skull base tumor patients with titanium microclip dural reconstruction were included in our case series. Lateral skull base pathologies represented in this group included two jugular foramen schwannomas, one vestibular schwannoma, one petroclival meningioma, one glomus jugulare paraganglioma, and one jugular foramen chordoid meningioma.

Conclusion To our knowledge, this is the first report on the use of microclips in repairing dural defects following lateral skull base surgery. Surgical outcomes for this small case series suggest that dural repair of the later skull base with nonpenetrating titanium microclips is a useful adjunct in dural repair following lateral skull base surgery.

Occipital condyle screw fixation after posterior decompression for Chiari malformation: Technical report and application

BACKGROUND

Surgical techniques for stabilization of the occipital cervical junction have traditionally consisted of screw-based techniques applied in conjunction with occipital plating and rods connected to subaxial instrumentation in the form of pars, pedicle, or lateral mass screws. In patients with type 1 Chiari malformation (CM-1) and evidence of occipital cervical junction instability who have undergone posterior decompression, the occipital condyle (OC) represents a potential alternative cranial fixation point. To date, this technique has only been described in pediatric case reports and morphometric cadaver studies.

METHODS

Patients underwent posterior fossa decompression for treatment of CM. Subsequently, patients received occipital cervical stabilization using OC screws.

RESULTS

Patients were successfully treated with no post-operative morbidity. Patient 2 was found to have pseudoarthrosis and underwent revision. Both patients continue to do well at 1-year follow-up.

CONCLUSION

Placement of the OC screw offers advantages over traditional plate-based occipital fixation in that bone removal for suboccipital decompression is not compromised by the need for hardware placement, screws are hidden underneath ample soft tissue in patients with thin skin which prevents erosion, and the OC consists of primarily cortical bone which provides for robust tricortical fixation. These cases demonstrate the novel application of the OC screw fixation technique to the treatment of occipital cervical junction instability in adult patients undergoing simultaneous posterior fossa decompression.

Conductive and injectable hyaluronic acid/gelatin/gold nanorod hydrogels for enhanced surgical translation and bioprinting

There is growing evidence indicating the need to combine the rehabilitation and regenerative medicine fields to maximize functional recovery after spinal cord injury (SCI), but there are limited methods to synergistically combine the fields. Conductive biomaterials may enable synergistic combination of biomaterials with electric stimulation (ES), which may enable direct ES of neurons to enhance axon regeneration and reorganization for better functional recovery; however, there are three major challenges in developing conductive biomaterials: (1) low conductivity of conductive composites, (2) many conductive components are cytotoxic, and (3) many conductive biomaterials are pre-formed scaffolds and are not injectable. Pre-formed, noninjectable scaffolds may hinder clinical translation in a surgical context for the most common contusion-type of SCI. Alternatively, an injectable biomaterial, inspired by lessons from bioinks in the bioprinting field, may be more translational for contusion SCIs. Therefore, in the current study, a conductive hydrogel was developed by incorporating high aspect ratio citrate-gold nanorods (GNRs) into a hyaluronic acid and gelatin hydrogel. To fabricate nontoxic citrate-GNRs, a robust synthesis for high aspect ratio GNRs was combined with an indirect ligand exchange to exchange a cytotoxic surfactant for nontoxic citrate. For enhanced surgical placement, the hydrogel precursor solution (i.e., before crosslinking) was paste-like, injectable/bioprintable, and fast-crosslinking (i.e., 4 min). Finally, the crosslinked hydrogel supported the adhesion/viability of seeded rat neural stem cells in vitro. The current study developed and characterized a GNR conductive hydrogel/bioink that provided a refinable and translational platform for future synergistic combination with ES to improve functional recovery after SCI.

Boomer Sooner: neurosurgery at the University of Oklahoma

Neurosurgery at the University of Oklahoma has played a pivotal role in the development of the specialty in the state. Its history spans nearly 90 years, beginning in 1931 when Dr. Harry Wilkins established the first neurosurgical practice in the state at the University of Oklahoma. Together with his first trainee, Dr. Jess Herrmann, Wilkins established the Division of Neurosurgery and its training program in 1946. Through their tireless work, the division and its residency program gained renown for its patient care and teaching, and this tradition was carried forward by its subsequent leaders. The Department of Neurosurgery was established in 1993. From humble beginnings, neurosurgery at the University of Oklahoma has grown a comprehensive residency program with an intensive curriculum, leveraging the clinical and academic breadth afforded by relationships with the College of Medicine, the University of Oklahoma Health Sciences Center, and allied clinical and research partners. Here, the authors recount the history of neurosurgery at the University of Oklahoma, the flagship academic neurosurgical program in the state.

A rare giant mixed germ cell tumor of the pineal region with immature elements: Case report and review of the literature

The diagnosis and management of mixed intracranial germ cell tumors may be complicated by the diversity present within this tumor category. Mixed germ cell tumors demonstrate variable natural histories which may be altered by the inclusion of even the most minute immature histological components. We report the case of an 18-year-old male who presented with a 3-month history of progressive headache and nausea leading to lethargy. Imaging revealed a giant pineal region mass extending superiorly from the roof of the fourth ventricle into the lateral ventricle, with resultant obstructive hydrocephalus. No spinal lesions were noted. Following gross total resection, the patient experienced marked improvement. Pathologic analysis identified an uncommon tumor composition: mature teratoma (96%), immature teratoma (2%), and germinoma (2%). Guided by the immature component, chemotherapy and radiation were added post-operatively to provide this patient with the greatest chance of long-term survival. Intracranial pathology, including germ cell tumors, should be included in the differential for any young patient presenting with new and progressive headache and nausea. This case emphasizes the benefit of a multimodal approach to mixed germ cell tumors of the pineal region and the importance of careful pathologic review of all submitted material.

Dynamic Occlusion of Distal Ventriculoperitoneal Shunt Catheter after Infusion Port Placement: A New Shunt Malfunction

Shunt failure requiring reintervention remains a common complication of hydrocephalus treatment. Here, we report a novel cause of mechanical shunt obstruction in an adult patient: position-dependent intermittent occlusion via an infusion port catheter. A 51-year-old woman with a grade II oligodendroglioma presented in a delayed fashion following surgery with a pseudomeningocele. She underwent ventriculoperitoneal shunt placement due to communicating hydrocephalus, resolving her pseudomeningocele. Shortly thereafter, she underwent placement of a subclavian infusion port at an outside institution. Her pseudomeningocele returned. Imaging demonstrated close proximity of her port catheter to the shunt catheter overlying the clavicle. Her shunt was tapped demonstrating a patent ventricular catheter with normal pressure. She underwent shunt exploration after her pseudomeningocele did not respond to valve adjustment. Intraoperative manometry demonstrated head position-dependent distal catheter obstruction. Repeat manometry following distal catheter revision demonstrated normal runoff independent of position. Her pseudomeningocele was resolved on follow-up. To our knowledge, this is the only reported case of intermittent, position-dependent distal catheter obstruction. Shunted patients with concern for malfunction following subclavian infusion port placement should be evaluated for possible dynamic obstruction of their distal catheter when the two catheters are in close proximity along the clavicle.

Cerebral venous thrombosis of the sphenoparietal sinus: A case report

Background:

Cerebral venous thrombosis (CVT) is a rare cause of stroke that preferentially affects reproductive aged females and patients with hereditary or acquired thrombotic risk factors. The superior sagittal sinus and transverse sinus are the two most common sites for thrombus formation.

Case Description:

We report a case of CVT arising in a very rare location, the sphenoparietal sinus. A 32-year-old woman with a history of factor V Leiden mutation and multiple prior episodes of venous thromboembolism presented with a new-onset seizure, headache, and emesis. CT angiography ultimately revealed thrombosis of the left sphenoparietal sinus. The patient received anticoagulation with apixaban with resolution of symptoms and without complications.

Conclusion:

This case serves as an uncommon example of sphenoparietal sinus thrombosis managed with novel oral anticoagulant treatment.

Parcellation-based anatomic model of the semantic network

INTRODUCTION

The semantic network is an important mediator of language, enabling both speech production and the comprehension of multimodal stimuli. A major challenge in the field of neurosurgery is preventing semantic deficits. Multiple cortical areas have been linked to semantic processing, though knowledge of network connectivity has lacked anatomic specificity. Using attentional task-based fMRI studies, we built a neuroanatomical model of this network.

METHODS

One hundred and fifty-five task-based fMRI studies related to categorization of visual words and objects, and auditory words and stories were used to generate an activation likelihood estimation (ALE). Cortical parcellations overlapping the ALE were used to construct a preliminary model of the semantic network based on the cortical parcellation scheme previously published under the Human Connectome Project. Deterministic fiber tractography was performed on 25 randomly chosen subjects from the Human Connectome Project, to determine the connectivity of the cortical parcellations comprising the network.

RESULTS

The ALE analysis demonstrated fourteen left hemisphere cortical regions to be a part of the semantic network: 44, 45, 55b, IFJa, 8C, p32pr, SFL, SCEF, 8BM, STSdp, STSvp, TE1p, PHT, and PBelt. These regions showed consistent interconnections between parcellations. Notably, the anterior temporal pole, a region often implicated in semantic function, was absent from our model.

CONCLUSIONS

We describe a preliminary cortical model for the underlying structural connectivity of the semantic network. Future studies will further characterize the neurotractographic details of the semantic network in the context of medical application.

Primary Repair of Posteriorly Located Anterior Skull Base Dural Defects Using Nonpenetrating Titanium Clips in Cranial Trauma

Objective Primary repair of posteriorly located anterior skull base (ASB) dural defects following cranial trauma is made difficult by narrow operative corridors and adherent dura mater. Inadequate closure may result in continued cerebrospinal fluid (CSF) leak and infectious sequelae. Here, we report surgical outcomes following the use of nonpenetrating titanium microclips as an adjunctive repair technique in traumatic anterior skull base dural defects extending from the olfactory groove to the tuberculum sellae.

Methods All trauma patients who underwent a bifrontal craniotomy from January 2013 to October 2019 were retrospectively reviewed. Patients with ASB defects located at posterior to the olfactory groove were analyzed. Patients with isolated frontal sinus fractures were excluded. All patients presented with CSF leak or radiographic signs of dural compromise. Patients were divided according to posterior extent of injury. Patient characteristics, imaging, surgical technique, and outcomes are reported.

Results A total of 19 patients who underwent a bifrontal craniotomy for repair of posteriorly located ASB dural defects using nonpenetrating titanium microclips were included. Defects were divided by location: olfactory groove (10/19), planum sphenoidale (6/19), and tuberculum sellae (3/19). No patients demonstrated a postoperative CSF leak. No complications related to the microclip technique was observed. Clip artifact did not compromise postoperative imaging interpretation.

Conclusion Primary repair of posteriorly located ASB dural defects is challenging due to narrow working angles and thin dura mater. Use of nonpenetrating titanium microclips for primary repair of posteriorly located dural defects is a reasonable adjunctive repair technique and was associated with no postoperative CSF leaks in this cohort.

Headache outcomes after surgery for pineal cyst without hydrocephalus: A systematic review

Background:

Pineal cysts are common entities, with a reported prevalence between 10 and 54%. Management of pineal cysts has historically been expectant, with surgical treatment of these lesions usually reserved for patients with a symptomatic presentation secondary to mass effect. The appropriate management of pineal cysts in patients presenting with headache in the absence of hydrocephalus – often the most common clinical scenario – has been more ambiguous. Here, we report the results of a comprehensive systematic review of headache outcomes for surgically treated, non-hydrocephalic pineal cyst patients without signs of increased intracranial pressure (ICP).

Methods:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to construct a systematic review. A comprehensive search of the PubMed, Embase, Scopus, and Web of Science databases was conducted from through June 2020. Relevant English-language articles were identified using the search terms “pineal cyst” and “headache.” The following eligibility criteria were applied: the inclusion of at least one surgically-treated, non-hydrocephalic pineal cyst patient presenting with headache in the absence of hemorrhage or signs and symptoms of increased ICP. Patient demographics and post-operative headache outcomes for the included studies were extracted and summarized.

Results:

A total of 24 pineal cyst cases meeting our selection criteria were identified across 11 included studies. Postoperative improvement or resolution of headaches was reported for 23/24 patients. Our systematic review of the literature demonstrates that non-hydrocephalic patients with pineal cysts have a high rate of headache improvement following surgical intervention.

Conclusion:

The results indicate a need for further investigation of the link between headache and pineal cysts in the non-hydrocephalic patient.

Rosette-forming glioneuronal tumor: an illustrative case and a systematic review

Background

Rosette-forming glioneuronal tumors (RGNTs) are rare, low-grade, primary CNS tumors first described in 2002 by Komori et al. RGNTs were initially characterized as a World Health Organization (WHO) grade I tumors typically localized to the fourth ventricle. Although commonly associated with an indolent course, RGNTs have the potential for aggressive behavior.

Methods

A comprehensive search of PubMed and Web of Science was performed through November 2019 using the search term “rosette-forming glioneuronal tumor.” Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. English, full-text case reports and series with histopathological confirmation were included. Patient demographics, presentations, MRI features, tumor location, treatment, and follow-up of all 130 cases were extracted.

Results

A 19-year-old man with a history of epilepsy and autism presented with acute hydrocephalus. MRI scans from 2013 to 2016 demonstrated unchanged abnormal areas of cortex in the left temporal lobe with extension into the deep gray-white matter. On presentation to our clinic in 2019, the lesion demonstrated significant progression. The patient’s tumor was identified as RGNT, WHO grade I. One hundred thirty patients were identified across 80 studies.

Conclusion

RGNT has potential to transform from an indolent tumor to a tumor with more aggressive behavior. The results of our systematic review provide insight into the natural history and treatment outcomes of these rare tumors.

Laser Interstitial Thermal Therapy Case Series: Choosing the Correct Number of Fibers Depending on Lesion Size

BACKGROUND

Laser interstitial thermal therapy (LITT) is being used for the treatment of recurrent glioblastoma multiforme (GBM). Lesions can be treated using 1 or multiple LITT fibers depending on the preference of surgeons. Usually, more fibers are needed for coverage of larger tumors.

OBJECTIVE

To investigate and analyze how tumor size affected the number of LITT fibers used.

METHODS

This is a retrospective review of patients undergoing treatment of recurrent GBM. Patients were treated with up to 4 LITT fibers for adequate tumor coverage. Patient demographics, tumor characteristics, length of stay, complications, and biopsy results were recorded.

RESULTS

A total of 43 cases were treated using LITT, and of these cases, 31 consisted of contiguous lesions. We used more fibers to treat larger tumor volumes. On average, for each 5 cc of tumor volume, a fiber was added for proper coverage (P = .554). Complications and length of stay were similar across the groups (P = .378, P = .941).

CONCLUSION

LITT can be used for the treatment of recurrent GBM. For each 5 cc of tumor volume, a LITT fiber can be added to the treatment plan.

Laser Interstitial Thermal Therapy for Metastatic Melanoma After Failed Radiation Therapy: A Case Series

BACKGROUND

Laser interstitial thermal therapy (LITT) is a growing technology to treat a variety of brain lesions. It offers an alternative to treatment options, such as open craniotomy and stereotactic radiosurgery.

OBJECTIVE

To analyze our experience using LITT for metastatic melanoma.

METHODS

This is a retrospective chart review of the patients from our institution. Our case series involves 5 patients who had previously failed radiation treatment.

RESULTS

Our patients have low complication rates and short hospital stays. Both are considerably lower when compared to the literature for metastatic melanoma.

CONCLUSION

LITT is a safe therapy, with few complications and short hospital stays.

Diffusion Tensor Imaging Tractography for Fornix Identification in Intraventricular Tumor Surgery: A Case Series

BACKGROUND

The proximity of intraventricular or periventricular tumors to critical white matter structures, such as the fornix, poses an operative challenge. In order to avoid significant neurological morbidity, deliberate selection of surgical approach is necessary when planning resection of tumors in this region. We report our initial experience with fornix modeling as an adjunct to standard navigational techniques across multiple pathologies.

OBJECTIVE

To report the feasibility of using diffusion tensor imaging (DTI) fornix modeling as an adjunct to standard navigational techniques for surgical treatment of intraventricular and periventricular tumors involving the fornix.

METHODS

Between July 2018 and August 2019, DTI tractography was performed on 12 patients with intraventricular or periventricular tumors involving the fornix. DTI fornix modeling was performed and included as part of the intraoperative navigation in all cases.

RESULTS

The patient group was composed of 6 males and 6 females. The fornix model was delineated in all cases using DTI tractography as described. The mean patient age was 45.7 yr. The 2 most-common tumor pathologies represented in our patient cohort included meningioma and cranipharyngioma, both found in 2 patients. A glioneuronal tumor, low-grade glioma, ependymoma, subependymoma, mixed germ-cell tumor, pituitary adenoma, and renal cell carcinoma metastasis were found in 1 patient each. Case examples of fornix modeling that may be incorporated into standard neuronavigation are presented. No patient experienced new or worsening post-operative memory deficits.

CONCLUSION

DTI tractography for fornix identification is a useful adjunct to standard navigational techniques employed in surgical resection of forniceal involving tumors.

Cryptococcal Choroid Plexitis and Non-Communicating Hydrocephalus

Cryptococcus neoformans is a fungus that commonly invades the central nervous system. While the choroid plexus, the site of the blood-cerebrospinal fluid barrier, serves as one potential entry point for the pathogen, disease involvement of the choroid plexus itself remains a very rare manifestation of Cryptococcus infection. In cases in which choroid plexus involvement blocks cerebrospinal fluid flow, obstructive hydrocephalus may occur. Here we report the case of a 63-year-old woman who presented with choroid plexitis causing obstructive hydrocephalus at the foramen of Monro. Endoscopic biopsy confirmed Cryptococcus neoformans, and the patient was successfully treated with amphotericin, flucytosine, and fluconazole. With proper recognition and treatment of this pathology, patients can fully recover from this condition.

Solitary osteochondroma of the cervical spine presenting with quadriparesis and hand contracture

Background

Spinal osteochondromas are rare, benign tumors arising from the cartilaginous elements of the spine that may appear as solitary lesions versus multiple lesions in patients with hereditary multiple exostoses. Here, we present a 15-year-old female with a solitary C3-C4 osteochondroma who presented with a progressive quadriparesis and hand contracture successfully managed with a laminectomy/posterior spinal fusion.

Case Description

A 15-year-old female presented with a 3-month history of progressive quadriparesis and hand contracture secondary to a magnetic resonance (MR) documented C3-C4 cervical spine osteochondroma. The MR imaging revealed a solitary osseous extramedullary outgrowth arising from the left laminar cortex of the C-3 vertebral body extending to C-4. Due to the marked resultant canal stenosis, the patient underwent a cervical laminectomy of C3- C4 with posterior spinal fusion. Gross total resection was achieved, and the pathology confirmed an osteochondroma. The patient's myelopathy resolved, and 2 years later, she demonstrated no residual deficits or tumor recurrence.

Conclusion

Here, we report the successful management of a 15-year-old female with a C3-C4 osteochondroma and progressive quadriparesis through cervical laminectomy/fusion.

Surgical Treatment of Tethered Cord Syndrome in Adults: A Systematic Review and Meta-Analysis

OBJECTIVE

In the healthy spine, the spinal cord moves unimpeded with spinal fluid pulsation in the rostral and caudal directions. When a portion of the spinal cord becomes attached to lesions within the spinal column, excess strain can cause signs and symptoms such as pain, motor deficits, sensory deficits, bladder dysfunction, and bowel dysfunction. This condition is termed tethered cord syndrome. There are no clear guidelines for offering surgical intervention, although there is a general consensus that worsening signs and symptoms increase the likelihood that patients will need surgery.

METHODS

In this article, we conduct a systematic review and meta-analysis for all available literature within the Ovid (MEDLINE), PubMed, and Google Scholar databases to evaluate common symptoms among patients with tethered cord and to examine how surgery affects symptoms.

RESULTS

Within the cohort of 730 patients, 708 (97%) were treated surgically by a detethering procedure. The most common preoperative sign or symptom was pain (81%), followed by motor deficits (63%), sensory deficits (61%), bladder dysfunction (56%), and bowel dysfunction (15%). One percent of patients had no deficit or symptom. Pain was the symptom that was most responsive to surgery, with 81% of patients reporting that their pain improved after detethering.

CONCLUSIONS

Tethered cord syndrome should be included in the differential diagnosis in patients presenting with back or leg pain, somatosensory symptoms of the lower extremities, muscular weakness, urodynamic dysfunction, or bowel dysfunction. After a definitive diagnosis is made, patients should be counseled about surgical detethering as an option.

A Connectomic Atlas of the Human Cerebrum-Chapter 8: The Posterior Cingulate Cortex, Medial Parietal Lobe, and Parieto-Occipital Sulcus

In this supplement, we build on work previously published under the Human Connectome Project. Specifically, we seek to show a comprehensive anatomic atlas of the human cerebrum demonstrating all 180 distinct regions comprising the cerebral cortex. The location, functional connectivity, and structural connectivity of these regions are outlined, and where possible a discussion is included of the functional significance of these areas. In part 8, we specifically address regions relevant to the posterior cingulate cortex, medial parietal lobe, and the parieto-occipital sulcus.

A Connectomic Atlas of the Human Cerebrum-Chapter 6: The Temporal Lobe

In this supplement, we build on work previously published under the Human Connectome Project. Specifically, we show a comprehensive anatomic atlas of the human cerebrum demonstrating all 180 distinct regions comprising the cerebral cortex. The location, functional connectivity, and structural connectivity of these regions are outlined, and where possible a discussion is included of the functional significance of these areas. In part 6, we specifically address regions relevant to the temporal lobe.

Flat-Detector CT to Quantify Response to Intra-Arterial Spasmolytic Therapy for Cerebral Vasospasm

BACKGROUND AND PURPOSE

Cerebral vasospasm in the setting of subarachnoid hemorrhage causes morbidity and mortality due to delayed cerebral ischemia and permanent neurological deficits. Vasospasm treatment includes intra-arterial injection of a spasmolytic during cerebral angiography. To evaluate effectiveness, neurointerventionalists subjectively examine a posttreatment cerebral angiogram to determine change in vessel diameter or increase in microvascular perfusion. Flat-detector computed tomography (FDCT) scanner has the ability to quantitatively measure cerebral blood volume (CBV) within the parenchyma and detect a quantitative change following treatment.

METHODS

This is a prospective study at a single institution between October 5, 2017 and June 3, 2019 that examines CBV studies from the Artis Q biplane (Siemens). Regions of interest were made in various territories to measure the CBV within the parenchyma before and after treatment with the spasmolytic verapamil. All instances of vasospasm involved vasculature within the left middle cerebral artery or internal carotid artery. The Wilcoxon signed-rank test was used to determine significance before and after treatment.

RESULTS

Our cohort consists of 6 patients who underwent Digital Subtraction Angiography (DSA) and FDCT scans for cerebral vasospasm within the left hemisphere. After intra-arterial injection of 20 mg of verapamil, average increases in blood volume were 59%, 22%, and 24% for the temporal, frontal, and parietal lobes, respectively. P-values associated were .03. We also observed decrease in the mean arterial blood pressure and transcranial Doppler values after treatment.

CONCLUSION

In conclusion, FDCT could measure the effectiveness of a change in CBV from infusion of verapamil in the setting of cerebral vasospasm. The authors believe quantifying the change allows for reassurance of improvement of cerebral vasospasm.

Embolization and Open Decompression of a Giant Aneurysm Involving the P2 Segment of the Posterior Cerebral Artery

A 5-year-old girl was brought to the clinic because of chronic intermittent left-sided headaches. The patient underwent computed tomographic angiography, which demonstrated a giant aneurysm that involved the P2 segment of the left posterior cerebral artery. Before treatment proceeded, consent was obtained from the patient's legal guardian. A trapping-evacuation technique was used for proximal control and decompression so that a clip could be placed on the proximal inflow artery of the aneurysm. First, embolization was performed for aneurysm trapping and for sacrifice of the parent vessel. Two days later, the patient was taken to the operating room for open surgical decompression, clipping, and reconstruction. Heparin was administered during the embolization stage of the operation. The patient did well postoperatively and was discharged home. The 3-month follow-up evaluation demonstrated a right superior homonymous quadrantanopia and no other neurologic deficits. The patient's clinical course is summarized in Video 1.

The Artery of Aphasia, A Uniquely Sensitive Posterior Temporal Middle Cerebral Artery Branch that Supplies Language Areas in the Brain: Anatomy and Report of Four Cases

BACKGROUND

Arterial disruption during brain surgery can cause devastating injuries to wide expanses of white and gray matter beyond the tumor resection cavity. Such damage may occur as a result of disrupting blood flow through en passage arteries. Identification of these arteries is critical to prevent unforeseen neurologic sequelae during brain tumor resection. In this study, we discuss one such artery, termed the artery of aphasia (AoA), which when disrupted can lead to receptive and expressive language deficits.

METHODS

We performed a retrospective review of all patients undergoing an awake craniotomy for resection of a glioma by the senior author from 2012 to 2018. Patients were included if they experienced language deficits secondary to postoperative infarction in the left posterior temporal lobe in the distribution of the AoA. The gross anatomy of the AoA was then compared with activation likelihood estimations of the auditory and semantic language networks using coordinate-based meta-analytic techniques.

RESULTS

We identified 4 patients with left-sided posterior temporal artery infarctions in the distribution of the AoA on diffusion-weighted magnetic resonance imaging. All 4 patients developed substantial expressive and receptive language deficits after surgery. Functional language improvement occurred in only 2/4 patients. Activation likelihood estimations localized parts of the auditory and semantic language networks in the distribution of the AoA.

CONCLUSIONS

The AoA is prone to blood flow disruption despite benign manipulation. Patients seem to have limited capacity for speech recovery after intraoperative ischemia in the distribution of this artery, which supplies parts of the auditory and semantic language networks.