Age-Related Changes in the Temperature of the Lumbar Spine Measured by Passive Microwave Radiometry (MWR)

A study was conducted to determine the age dependence of the temperature of the low back in the region of the five lumbar vertebrae by using passive microwave radiometry (MWR). The rationale for the study is that the infrared brightness on which the temperature measurement is based will be dependent upon blood circulation and thus on metabolic, vascular, and other regulatory factors. The brightness and infrared temperatures were determined in five zones above each of the medial, left, and right lateral projections of the vertebrae. A total of 115 healthy subjects were recruited, aged between 18 and 84 years. No significant differences in infrared temperature were detected. As predicted, brightness temperature increased until 25 years old and then gradually decreased. In subjects over 70 years of age, compared with those aged 60-70 years, there is a significant increase in brightness temperature at the level of 3-5 lumbar vertebrae by 0.3-0.7 °C. This is interpreted as indicating that individuals who have lived to an advanced age successfully maintain metabolic and regenerative processes. The benchmark data that has been obtained can be usefully employed in future studies of the aetiology of low back pain. In particular, the prospect exists for the technology to be used to provide a non-invasive biomarker to evaluate the effectiveness of antiaging therapies.

Impact of a Perioperative Protocol on Length of ICU and Hospital Stay in Complex Spine Surgery

BACKGROUND

In an attempt to improve patient care, a perioperative complex spine surgery management protocol was developed through collaboration between spine surgeons and neuroanesthesiologists. The aim of this study was to investigate whether implementation of the protocol in 2015 decreased total hospital and intensive care unit (ICU) length of stay (LOS) and complication rates after elective complex spine surgery.

MATERIALS AND METHODS

A retrospective cohort study was conducted by review of the medical charts of patients who underwent elective complex spine surgery at an academic medical center between 2012 and 2017. Patients were divided into 2 groups based on the date of their spine surgery in relation to implementation of the spine surgery protocol; before-protocol (January 2012 to March 2015) and protocol (April 2015 to March 2017) groups. Outcomes in the 2 groups were compared, focusing on hospital and ICU LOS, and complication rates.

RESULTS

A total of 201 patients were included in the study; 107 and 94 in the before-protocol and protocol groups, respectively. Mean (SD) hospital LOS was 14.8±10.8 days in the before-protocol group compared with 10±10.7 days in the protocol group (P<0.001). The spine surgery protocol was the primary factor decreasing hospital LOS; incidence rate ratio 0.78 (P<0.001). Similarly, mean ICU LOS was lower in the protocol compared with before-protocol group (4.2±6.3 vs. 6.3±7.3 d, respectively; P=0.011). There were no significant differences in the rate of postoperative complications between the 2 groups (P=0.231).

CONCLUSION

Implementation of a spine protocol reduced ICU and total hospital LOS stay in high-risk spine surgery patients.

ENIGMA and global neuroscience: A decade of large-scale studies of the brain in health and disease across more than 40 countries

This review summarizes the last decade of work by the ENIGMA (Enhancing NeuroImaging Genetics through Meta Analysis) Consortium, a global alliance of over 1400 scientists across 43 countries, studying the human brain in health and disease. Building on large-scale genetic studies that discovered the first robustly replicated genetic loci associated with brain metrics, ENIGMA has diversified into over 50 working groups (WGs), pooling worldwide data and expertise to answer fundamental questions in neuroscience, psychiatry, neurology, and genetics. Most ENIGMA WGs focus on specific psychiatric and neurological conditions, other WGs study normal variation due to sex and gender differences, or development and aging; still other WGs develop methodological pipelines and tools to facilitate harmonized analyses of "big data" (i.e., genetic and epigenetic data, multimodal MRI, and electroencephalography data). These international efforts have yielded the largest neuroimaging studies to date in schizophrenia, bipolar disorder, major depressive disorder, post-traumatic stress disorder, substance use disorders, obsessive-compulsive disorder, attention-deficit/hyperactivity disorder, autism spectrum disorders, epilepsy, and 22q11.2 deletion syndrome. More recent ENIGMA WGs have formed to study anxiety disorders, suicidal thoughts and behavior, sleep and insomnia, eating disorders, irritability, brain injury, antisocial personality and conduct disorder, and dissociative identity disorder. Here, we summarize the first decade of ENIGMA's activities and ongoing projects, and describe the successes and challenges encountered along the way. We highlight the advantages of collaborative large-scale coordinated data analyses for testing reproducibility and robustness of findings, offering the opportunity to identify brain systems involved in clinical syndromes across diverse samples and associated genetic, environmental, demographic, cognitive, and psychosocial factors.

Implementing an infection control and prevention program decreases the incidence of healthcare-associated infections and antibiotic resistance in a Russian neuro-ICU

Background

The impact of infection prevention and control (IPC) programs in limited resource countries such as Russia are largely unknown due to a lack of reliable data. The aim of this study is to evaluate the effect of an IPC program with respect to healthcare associated infection (HAI) prevention and to define the incidence of HAIs in a Russian ICU.

Methods

A pioneering IPC program was implemented in a neuro-ICU at Burdenko Neurosurgery Institute in 2010 and included hand hygiene, surveillance, contact precautions, patient isolation, and environmental cleaning measures. This prospective observational cohort study lasted from 2011 to 2016, included high-risk ICU patients, and evaluated the dynamics of incidence, etiological spectrum, and resistance profile of four types of HAIs, including subgroup analysis of device-associated infections. Survival analysis compared patients with and without HAIs.

Results

We included 2038 high-risk patients. By 2016, HAI cumulative incidence decreased significantly for respiratory HAIs (36.1% vs. 24.5%, p-value = 0.0003), urinary-tract HAIs (29.1% vs. 21.3%, p-value = 0.0006), and healthcare-associated ventriculitis and meningitis (HAVM) (16% vs. 7.8%, p-value = 0.004). The incidence rate of EVD-related HAVM dropped from 22.2 to 13.5 cases per 1000 EVD-days. The proportion of invasive isolates of Klebsiella pneumoniae and Acinetobacter baumannii resistant to carbapenems decreased 1.7 and 2 fold, respectively. HAVM significantly impaired survival and independently increasing the probability of death by 1.43.

Conclusions

The implementation of an evidence-based IPC program in a middle-income country (Russia) was highly effective in HAI prevention with meaningful reductions in antibiotic resistance.

Electronic supplementary material

The online version of this article (10.1186/s13756-018-0383-4) contains supplementary material, which is available to authorized users.

Healthcare-associated ventriculitis and meningitis in a neuro-ICU: Incidence and risk factors selected by machine learning approach

PURPOSE

To define the incidence of healthcare-associated ventriculitis and meningitis (HAVM) in the neuro-ICU and to identify HAVM risk factors using tree-based machine learning (ML) algorithms.

METHODS

An observational cohort study was conducted in Russia from 2010 to 2017, and included high-risk neuro-ICU patients. We utilized relative risk analysis, regressions, and ML to identify factors associated with HAVM development.

RESULTS

2286 patients of all ages were included, 216 of them had HAVM. The cumulative incidence of HAVM was 9.45% [95% CI 8.25-10.65]. The incidence of EVD-associated HAVM was 17.2 per 1000 EVD-days or 4.3% [95% CI 3.47-5.13] per 100 patients. Combining all three methods, we selected four important factors contributing to HAVM development: EVD, craniotomy, superficial surgical site infections after neurosurgery, and CSF leakage. The ML models performed better than regressions.

CONCLUSION

We first reported HAVM incidence in a neuro-ICU in Russia. We showed that tree-based ML is an effective approach to study risk factors because it enables the identification of nonlinear interaction across factors. We suggest that the number of found risk factors and the duration of their presence in patients should be reduced to prevent HAVM.

Effects of Anesthetic Management on Early Postoperative Recovery, Hemodynamics and Pain After Supratentorial Craniotomy

Various clinical trials have assessed how intraoperative anesthetics can affect early recovery, hemodynamics and nociception after supratentorial craniotomy. Whether or not the difference in recovery pattern differs in a meaningful way with anesthetic choice is controversial. This review examines and compares different anesthetics with respect to wake-up time, hemodynamics, respiration, cognitive recovery, pain, nausea and vomiting, and shivering. When comparing inhalational anesthetics to intravenous anesthetics, either regimen produces similar recovery results. Newer shorter acting agents accelerate the process of emergence and extubation. A balanced inhalational/intravenous anesthetic could be desirable for patients with normal intracranial pressure, while total intravenous anesthesia could be beneficial for patients with elevated intracranial pressure. Comparison of inhalational anesthetics shows all appropriate for rapid emergence, decreasing time to extubation, and cognitive recovery. Comparison of opioids demonstrates similar awakening and extubation time if the infusion of longer acting opioids was ended at the appropriate time. Administration of local anesthetics into the skin, and addition of corticosteroids, NSAIDs, COX-2 inhibitors, and PCA therapy postoperatively provided superior analgesia. It is also important to emphasize the possibility of long-term effects of anesthetics on cognitive function. More research is warranted to develop best practices strategies for the future that are evidence-based.

[Primary and re-arthroplasty of the hip or knee joints in patients 80 years of age and older]

Due to the ageing of the population, more and more patients older than 80 years are in need of the hip and knee joints total endoprosthesis. The aim of this retrospective study was to describe perioperative mortality and frequency of complications associated with both primary and re-arthroplasty of hip and knee joints in this age group. For more information about demography, the perioperational period and frequency of complications were investigated 59 patient's card, who have had a 71 endoprosthesis operations, carried out by one surgeon. Information on mortality was obtained by means of telephone interviewing. The average level of mortality within 30 days, 1 year and 5 years amounted to 2.0, 6.1 and 10.2% respectively. Compared with other studies conducted over the past 20 years, these results reflect a significant reduction in the mortality, rate. Average frequency of complications in our study was to 52.2%. which corresponds to the previously published data. All the complications were eliminated and did not cause permanent disability. Thanks to the development of anaesthesia, surgical techniques and technologies, joint endoprosthetics can be considered safe in patients older than 80 years.

Early postoperative cognitive dysfunction and postoperative delirium after anaesthesia with various hypnotics: study protocol for a randomised controlled trial--the PINOCCHIO trial

Background

Postoperative delirium can result in increased postoperative morbidity and mortality, major demand for postoperative care and higher hospital costs. Hypnotics serve to induce and maintain anaesthesia and to abolish patients' consciousness. Their persisting clinical action can delay postoperative cognitive recovery and favour postoperative delirium. Some evidence suggests that these unwanted effects vary according to each hypnotic's specific pharmacodynamic and pharmacokinetic characteristics and its interaction with the individual patient.

We designed this study to evaluate postoperative delirium rate after general anaesthesia with various hypnotics in patients undergoing surgical procedures other than cardiac or brain surgery. We also aimed to test whether delayed postoperative cognitive recovery increases the risk of postoperative delirium.

Methods/Design

After local ethics committee approval, enrolled patients will be randomly assigned to one of three treatment groups. In all patients anaesthesia will be induced with propofol and fentanyl, and maintained with the anaesthetics desflurane, or sevoflurane, or propofol and the analgesic opioid fentanyl.

The onset of postoperative delirium will be monitored with the Nursing Delirium Scale every three hours up to 72 hours post anaesthesia. Cognitive function will be evaluated with two cognitive test batteries (the Short Memory Orientation Memory Concentration Test and the Rancho Los Amigos Scale) preoperatively, at baseline, and postoperatively at 20, 40 and 60 min after extubation.

Statistical analysis will investigate differences in the hypnotics used to maintain anaesthesia and the odds ratios for postoperative delirium, the relation of early postoperative cognitive recovery and postoperative delirium rate. A subgroup analysis will be used to categorize patients according to demographic variables relevant to the risk of postoperative delirium (age, sex, body weight) and to the preoperative score index for delirium.

Discussion

The results of this comparative anaesthesiological trial should whether each the three hypnotics tested is related to a significantly different postoperative delirium rate. This information could ultimately allow us to select the most appropriate hypnotic to maintain anaesthesia for specific subgroups of patients and especially for those at high risk of postoperative delirium.

Registered at Trial.gov Number

ClinicalTrials.gov: NCT00507195

Neurosurgical center in Astana, capital of Kazakhstan

Formation of the Republican Scientific Center of Neurosurgery (RSCN) in Astana, the new capital of Kazakhstan, has allowed improvements in neurosurgery in this country on a qualitatively new level. The latest achievements in neuro-oncologic, spine, pediatric, and vascular neurosurgery are available in the RSCN. The center has come into being as a result of dynamic economic development in Kazakhstan. The RSCN is ready to become a leading neurosurgical center in the central Asia region.

Long-term outcomes and patterns of tumor progression after gamma knife radiosurgery for benign meningiomas

OBJECT

To characterize the timing and patterns of long-term treatment failure after Gamma Knife radiosurgery (GKRS) for benign meningiomas.

METHODS

Data were retrospectively reviewed in 116 patients who underwent 136 GKRS treatments for benign intracranial meningiomas from 1996 to 2004. Patients with atypical or malignant meningiomas were excluded. Surgical resection preceded GKRS in 72 patients (62%). The median tumor volume was 3.4 cm, and the median prescription dose to the 50% isodose line was 16 Gy.

RESULTS

The median follow-up time was 75 months (range, 4-146 months). Overall tumor control was achieved in 128 of 136 lesions (94%), of which tumor size was stable in 68% and decreased in 26%. Seven patients experienced disease progression in 8 tumors, occurring at a mean time of 90 months. The overall 5-year and 10-year actuarial tumor control rate was 98.9% and 84%, respectively. Characteristics corresponding to tumor progression included insufficient tumor coverage (98% vs 93%, P = .007), cavernous sinus lesions, and meningiomatosis. Complications after GKRS developed in 8% of patients, in whom the mean tumor volume was nearly double that in patients with no adverse effects (11 vs 5.7 cm3, P = .003).

CONCLUSIONS

GKRS demonstrates excellent long-term tumor control in the management of benign meningiomas. Tumor progression occurred at a mean time of 7.5 years after GKRS, reinforcing the need for long-term surveillance despite initial tumor control. Treatment failure was related to undercoverage of lesions in the majority of cases, with the remainder demonstrating evidence of abnormal tumor biology.

Postoperative Gamma Knife surgery for benign meningiomas of the cranial base

OBJECT

The standard treatment for meningiomas is complete resection, but the proximity of skull base meningiomas to important neurovascular structures makes complete excision of the lesion difficult or impossible. The authors analyzed the mid- and long-term results obtained in patients treated with postresection Gamma Knife surgery (GKS) for residual or recurrent benign meningiomas of the cranial base.

METHODS

Thirty-six patients with residual or recurrent benign meningiomas of the skull base following one or more surgical procedures underwent GKS. There were 31 women and five men, ranging in age from 22 to 73 years. The median tumor volume was 4.1 ml (range 0.8-20 ml) and the median radiation dose to the tumor margin was 16 Gy (range 15-16 Gy).

RESULTS

Patients were followed for a median of 81 months (range 30-141 months) after GKS. At the end of the follow-up period, overall neurological improvement was observed in 16 patients (44.4%), whereas the condition in 20 patients (55.6%) was unchanged. One patient suffered transient cerebral edema 6 months after GKS. Based on imaging documentation, a partial response was seen in five patients (13.9%), the disease remained stable in 30 patients (83.3%), and in one patient (2.8%) there was an increase in tumor size. The actuarial progression-free survival rate was 100% at 5 years and 94.7% at 10 years.

CONCLUSIONS

Gamma Knife surgery was shown to be an excellent adjunct to resection because of its durable rate of tumor control and low toxicity. It should be initially considered along with surgery for the treatment of complex skull base meningiomas.

Surgical outcomes in 118 patients with Rathke cleft cysts

OBJECT

Microscopic Rathke cleft cysts are a common incidental autopsy finding, but some Rathke cleft cysts can become sufficiently large to cause visual impairment, hypothalamic-pituitary dysfunction, and headaches. In this study patients were evaluated pre- and postoperatively to ascertain the clinical significance of surgical intervention on endocrine and visual improvement. Factors correlated with cyst recurrence were also evaluated.

METHODS

A retrospective analysis was conducted in 160 patients with Rathke cleft cysts who were treated between 1984 and 1995 and completed at least a 5-year follow-up period. Of these 160 patients, 118 initially exhibited symptoms of visual impairment or endocrine dysfunction, became symptomatic during the follow-up period, or were found to have cyst enlargement. These 118 patients underwent transsphenoidal surgery. Forty-two patients with incidental lesions that demonstrated no growth on magnetic resonance (MR) images were followed up without an operation. Complete resection, as observed on MR images 3 months postoperatively, was obtained in 114 (97%) of 118 patients. Vision improved postoperatively in 57 (98%) of 58 patients. Hypogonadism improved in 11 (18%) of 62 patients, growth hormone deficiency resolved in 14 (18%) of 78 patients, and hypocortisolemia resolved in one (14%) of seven patients. Twenty-two patients (19%) began to exhibit symptoms of diabetes insipidus, which had not been present preoperatively. The total 5-year recurrence rate was 18% (21 of 118 patients), with 12 patients requiring a repeated operation. Surgical and pathological factors that were found to be statistically associated with recurrence were the use of a fat and/or fascial graft for closure (p < 0.01) and the presence of squamous metaplasia in the cyst wall (p < 0.01). The extent of resection of the cyst wall was not associated with an increased rate of recurrence. In 42 (69%) of 61 patients the incidental cysts did not progress on imaging studies or clinically.

CONCLUSIONS

This is the largest series of patients with symptomatic Rathke cleft cysts who received operative intervention and participated in the longest postoperative follow up reported in the literature. The high recurrence rate (18%) supports the theory that a relationship exists between a symptomatic Rathke cleft cyst and craniopharyngioma. Improvements in visual and endocrine dysfunction can be expected after surgical decompression of the optic apparatus and the hypothalamic-pituitary axis.

GAMMA KNIFE RADIOSURGERY FOR BENIGN CAVERNOUS SINUS TUMORS: QUANTITATIVE ANALYSIS OF TREATMENT OUTCOMES

OBJECTIVE

We review our 8-year experience with gamma knife radiosurgery (GKRS) for the treatment of patients with benign cavernous sinus tumors and present a quantitative analysis of factors relevant to treatment outcomes.

METHODS

From 1994 to 2002, a total of 139 patients with benign cavernous sinus tumors were treated in 145 sessions. Their median age was 53 years, and the median follow-up was 3.5 years. The tumors included 57 meningiomas, 76 pituitary tumors (49 nonfunctional adenomas, 15 prolactinomas, 5 adrenocorticotropic hormone-secreting tumors, 6 growth hormone-secreting tumors, and 1 plurihormone-secreting tumor), 4 schwannomas, 1 hemangioma, and 1 paraganglioma. Sekhar tumor grades were as follows: I, n = 28 (20%); II, n = 42 (30%); III, n = 42 (30%); IV, n = 19 (14%); and V, n = 8 (6%). The median tumor volume was 3.4 cm(3), and the median prescribed dose was 15 Gy defined to the 50% isodose line.

RESULTS

A total of 136 treated tumors (97.8%) were well controlled by GKRS, with low morbidity. For meningiomas, 29 tumors (51%) were unchanged and 26 (46%) were smaller at a median of 15.2 months. For pituitary tumors, 50 (66%) were unchanged and 25 (33%) were smaller at a median of 20.6 months. Improvement in cranial nerve (CN) function was seen in 19 (36.5%) of 52 patients with pre-GKRS deficits, and 3 patients (2.2%) developed new stable CN deficits after GKRS: 1 patient developed IVth CN palsy at 9 months, and 2 developed persistent VIth CN palsies at 43 and 45 months, respectively, that required surgical correction. Two patients developed transient VIth CN palsies at 48 months that self-resolved after another year. Endocrine function normalized for all 6 treated patients with a growth hormone-secreting tumor at a median of 18 months. One of the 5 adrenocorticotropic hormone-secreting tumors required retreatment after 17 months because of continued cortisol elevation. Thirteen (87%) of 15 prolactinoma patients had normalized prolactin levels within 2 years of the procedure; 2 patients relapsed by endocrine criteria at 18 and 22 months after GKRS. Two patients with normalized prolactin levels completed three normal pregnancies within 3 years of treatment. Six patients (4.3%) with a median tumor volume of 8 cm(3) developed radiation-induced injury at a median of 36 months after GKRS. Five of these patients also underwent external beam radiotherapy and received a median dose of 52.2 Gy in 30 fractions. Quantitative analysis revealed that the radiation dose to critical structures (optic apparatus and pons) is correlated with their distance from tumor margins. Underdosed tumor volume, tumor volume, and total treated volume are correlated with treatment outcomes.

CONCLUSION

GKRS is a safe and effective treatment for selected patients with benign cavernous sinus tumors and is an important adjunct for treating postoperative tumor residual and/or recurrent tumor. Continued analysis of treated patients over an extended time is needed to evaluate long-term disease control and potential late GKRS complications.

Study of Magnetic Resonance Imaging-based Arteriovenous Malformation Delineation without Conventional Angiography

OBJECTIVE

In this study, we aimed to assess the feasibility of arteriovenous malformation (AVM) delineation for gamma knife radiosurgery without conventional angiography and to correlate factors that may affect AVM delineation.

METHODS

A series of 57 consecutive patients with AVMs treated with gamma knife radiosurgery from August 1994 to December 2000 were reviewed. All patients in the study had undergone pretreatment angiography. The mean AVM volume was 2.8 cm(3), with a median of 2.0 cm(3) (range, 0.04-22 cm(3)). All AVMs were delineated on the original frame-based magnetic resonance imaging (MRI) scans by a vascular neurosurgeon without the assistance of angiography and then compared with the actual AVM delineation on the basis of previously performed angiography and MRI. Univariate correlation analysis was used to determine the relationship of AVM coverage, size, diffuseness, previous embolization, and hemorrhage parameters.

RESULTS

The study volume or MRI-based volume alone coincided with the actual treatment volume by a mean of 58% for diffuse and 87% for nondiffuse AVMs (P = 0.0005). At AVM volume greater than 2 cm(3), the median percentage of coinciding volume was 63% for embolized AVMs and 82% for nonembolized AVMs (P = 0.0315). Conversely, the study volume overestimated the actual treatment volume by a mean of 57% for AVMs larger than 2 cm(3) versus 25% for AVMs smaller than 2 cm(3) (P = 0.0012). In general, the percentage of the coinciding volume was inversely related to that of the excess volume, whereas both the study volume and the coinciding volume were proportionate to AVM volume at treatment.

CONCLUSION

MRI-based AVM delineation without conventional angiography may be feasible only for selected patients, such as those with nondiffuse and large nonembolized AVMs.

The antinociceptive effect of the combination of spinal morphine with systemic morphine or buprenorphine

We sought to analyze the mode of interaction of spinal morphine with systemic morphine or buprenorphine, administered in a wide range of antinociceptive doses. The study was performed on Sprague-Dawley rats by using a plantar stimulation test and isobolographic and fractional analyses of drug interaction. The isobolographic and fractional analyses demonstrated that intrathecal morphine interacted with subcutaneous morphine in a synergistic manner while producing a 50% or 75% antinociceptive effect. The sum of D(75) fractions was more than that for 50% antinociception, suggesting a less dramatic interaction. The combination with a maximal relative dose of systemic morphine (0.66:1) showed a maximal degree of supraadditivity. The interaction between spinal morphine and systemic buprenorphine was similar to that of morphine/morphine, although the supra-additivity was not as pronounced. For the doses that produced a 50% antinociceptive effect, a synergistic interaction was observed only for the combination with a morphine/buprenorphine ratio of 1.33:1. When the relative amount of intrathecal morphine was decreased or increased, the effect became additive. At the doses that produced 75% antinociception, both combinations of morphine and buprenorphine demonstrated supraadditive interaction.

IMPLICATIONS

Spinal morphine interacts with systemic morphine or buprenorphine in asupraadditive manner. This mode of interaction most probably results from the simultaneous activation of spinal and supraspinal antinociceptive systems. Supraspinal structures played a more important role in the antinociceptive effect of experimental combinations than structures of the spinal cord.

A tribute to Dr. Fedor A. Serbinenko, founder of endovascular neurosurgery

From humble beginnings in the former Soviet Union, Fedor A. Serbinenko, M.D., Ph.D., became a leading figure at Moscow's famed Burdenko Neurosurgery Institute. While there, he invented and perfected the technique of balloon embolization, which was destined to change the practice of neurovascular surgery forever. We present the life and achievements of the father of endovascular neurosurgery.

Gamma knife radiosurgery for metastatic melanoma: an analysis of survival, outcome, and complications

OBJECTIVE

Although the mainstays for treatment of metastatic brain disease have been surgery and/or external beam radiation therapy, an increasing number of patients are being referred for stereotactic radiosurgery as the primary intervention for their intracranial pathological abnormalities. The lack of efficacy and cognitive and behavioral consequences of whole brain irradiation have prompted clinicians to select patients for alternative therapies. This study analyzes the effectiveness of Leksell gamma unit therapy for metastatic melanoma to the brain.

METHODS

We present our experience with 59 Leksell gamma unit treatment sessions in 45 consecutive patients who presented with metastatic melanoma to the brain. Five of these procedures were performed as salvage therapy for patients who needed second radiosurgical treatment for new lesions that were remote from the previous targets and were not included in the overall analyses.

RESULTS

The population included 78% male patients. The mean patient age was 53 years (age range, 24-80 yr). The mean time from diagnosis of primary melanoma to discovery of brain metastasis was 43 months (median, 27.5 mo; range, 1-180 mo). At the time of diagnosis of brain disease, 35.5% of the patients (16 of 45 patients) had neurological symptoms, 77.7% (35 of 45 patients) had known visceral metastases, and 11.1% (5 of 45 patients) had seizure disorders. Eighty-six percent of the lesions (80 of 93 lesions) were cortical, 12% (11 of 93 lesions) were cerebellar, 1% (1 of 93 lesions) were pontine, and 1% (1 of 93 lesions) were thalamic. Fifty-seven percent of the sessions (31 of 54 sessions) were performed for a single lesion, 24.1% (13 of 54 sessions) for two lesions, 9.2% (5 of 54 sessions) for three lesions, 7.4% (4 of 54 sessions) for four lesions, and 1.8% (1 of 54 sessions) for five lesions. The mean treatment volume was 5.6 cc, with a mean prescription of 21.6 Gy to the 56.0% mean isodose line. The median survival time of the patients in our population, using Kaplan-Meier curves, was 43 months from the time of diagnosis of primary melanoma (range, 3-180 mo) and 8 months (range, 1-20 mo) from the time of gamma knife treatment. Complications included seizures within 24 hours of the procedure in four patients, with transient nausea and vomiting in three patients, transient worsening of preprocedure paresis responsive to steroids in three patients, and increased confusion in one patient. All 45 patients were located for follow-up (mean follow-up duration, 1 yr). After gamma knife treatment, 78% of the patients (35 of 45 patients) experienced either improved or stable neurological symptomatology before death or at the time of the latest follow-up examination. There were 26 deaths (58%). The cause of death was determined to be neurological in only 2 of 45 patients (7.7%). Follow-up magnetic resonance images revealed a 97% local tumor control rate of gamma knife-treated lesions, with 28% radiographic disappearance (9 of 32 cases). Six patients developed new lesions remote from radiosurgical targets and underwent second procedures.

CONCLUSION

Although metastatic melanoma to the brain continues to have a foreboding prognosis for long-term survival, gamma knife radiosurgery seems to be a relatively safe, noninvasive, palliative therapy, halting or reversing neurological progression in 77.8% of treated patients (35 of 45 patients). The survival rate matches or exceeds those previously reported for surgery and other forms of radiotherapy. Only 7.7% of the patients in our study population who died as a result of metastatic melanoma (2 of 26 patients) died as a result of neurological disease. The routine use of therapeutic level antiseizure medication is emphasized, considering the findings of our review.

Spinal artery syndrome masked by postoperative epidural analgesia

PURPOSE

We report a case of a patient who developed a postoperative anterior spinal artery syndrome that was masked by the use of epidural analgesia. We wish to alert other anaesthetists that the use of epidural anaesthesia in this setting may mask the symptoms and delay the diagnosis of this rare complication.

CLINICAL FEATURES

The patient was a 22-yr-old obese man with metastatic testicular carcinoma who underwent a left-sided thoracoabdominal retroperitoneal tumour resection. A lumbar epidural catheter was placed preoperatively for pain management. Postoperatively, the patient developed bilateral lower extremity weakness, which was at first attributed to epidural administration of local anaesthetics. Despite discontinuation of the local anaesthetics, the symptoms persisted. Further work-up led to the diagnosis of anterior spinal artery syndrome. The patient was sent to a rehabilitation hospital and had a partial recovery.

CONCLUSION

Anterior spinal artery syndrome can occur following retroperitoneal surgery. It is important to recognize the potential for this complication when postoperative epidural analgesia is contemplated, especially following a left-sided surgical dissection. The use of epidural local anaesthetics immediately after surgery delays the diagnosis of a postoperative neurological deficit. Moreover, when the deficit is recognized the epidural itself may be falsely blamed for postoperative paraplegia. If epidural analgesia is used, opioids may be preferred over local anaesthetics in the immediate postoperative period to prevent masking of an anterior spinal artery syndrome.

Attenuation of brain injury and reduction of neuron-specific enolase by nicardipine in systemic circulation following focal ischemia and reperfusion in a rat model

A reversible middle cerebral artery occlusion was performed in rats to determine whether nicardipine, a dihydropyridine voltage-sensitive Ca++ channel (VSCC) antagonist, exerts neuroprotective effects when administered 10 minutes following an ischemic insult, and if it does, whether this is due to its vasodilatory action and effect on cerebral blood flow (CBF) or to direct blockade of Ca++ entry into ischemic brain cells. An increase in the intracellular calcium, [Ca++]i, plays a major role in neuronal injury during cerebral ischemia. Although a large amount of Ca++ enters neurons through the VSCC during ischemia, inconsistent neuroprotective effects have been reported with the antagonists of the VSCC. An intraperitoneal injection of nicardipine (1.2 mg/kg) was administered to rats 10 minutes after the onset of ischemia, and 8, 16, and 24 hours after occlusion. Cortical CBF was determined by laser-Doppler flowmetry. Neurological and neuropathological examinations were performed after 72 hours. Neuron-specific enolase, a specific marker for the incidence of neuronal injury, was measured in plasma. The CBF and other physiological parameters were not affected by nicardipine during occlusion or reperfusion. However, nicardipine treatment significantly improved motor neurological outcome by 29%, and the infarction and edema volume in the pallium as well as the edema volume in the striatum were significantly reduced by 27%, 37%, and 52%, respectively. Nicardipine also reduced the neuron-specific enolase plasma levels by 50%, 42%, and 59% at 24, 48, and 72 hours after the occlusion, respectively. It is concluded that nicardipine may attenuate focal ischemic brain injury by exerting direct neuroprotective and antiedematous effects that do not depend on CBF.

Rapid reversal of endothelin-1-induced cerebral vasoconstriction by intrathecal administration of nitric oxide donors

OBJECTIVE

To determine the capability of donors of nitric oxide (NO) (sodium nitroprusside, nitroglycerine) to reverse endothelin-1 (ET-1)-induced cerebral vasoconstriction in vivo, when administered through the cerebrospinal fluid (CSF) to the adventitial side of the constricted blood vessel.

METHODS

The rabbit basilar artery was exposed through a transcervical, transclival approach and subsequently subjected to pharmacological manipulations and direct observation of effects by videomicroscopy. Specific manipulations were suffusion of ET-1 (100 nmol/L, 1 ml/min) in synthetic CSF (sCSF) to provoke vasoconstriction and then either suffusion of an NO donor in sCSF (2 mg/ml/min), or sCSF alone. The second suffusion was always made separately and begun during the period of stable maximal vasoconstriction, which occurred between 20 and 30 minutes after beginning the first suffusion. Measurements of the diameter of the artery were made using an inline video caliper.

RESULTS

Sodium nitroprusside and nitroglycerine, both donors of NO, rapidly and completely reversed ET-1-induced vasoconstriction without causing hypotension. The average value for maximal vasoconstriction by ET-1/sCSF was 50.4% of baseline arterial diameter and occurred between 20 and 30 minutes. The rate of vasodilatory response was 100% of significantly constricted arteries. The response was complete in less than 6 minutes in all preparations, as compared to the 60 minutes required for spontaneous relaxation (sCSF suffusion alone).

CONCLUSION

NO donors are effective in reversing cerebral vasoconstriction when administered intrathecally, cause no significant hemodynamic change when so administered, and may represent an important therapeutic intervention for cerebral vasospasm.

Neuroprotective effects of nicardipine in a rat model of ischemia and reperfusion

A reversible middle cerebral artery occlusion was performed in rats to determine whether nicardipine, a dihydropyridine voltage-sensitive Ca++ channel (VSCC) antagonist, exerts neuroprotective effects when administered 10 minutes following an ischemic insult, and if it does, whether this is due to its vasodilatory action and effect on cerebral blood flow (CBF) or to direct blockade of Ca++ entry into ischemic brain cells. An increase in the intracellular calcium, [Ca++]i, plays a major role in neuronal injury during cerebral ischemia. Although a large amount of Ca++ enters neurons through the VSCC during ischemia, inconsistent neuroprotective effects have been reported with the antagonists of the VSCC. An intraperitoneal injection of nicardipine (1.2 mg/kg) was administered to rats at 10 minutes after the onset of ischemia, and 8, 16, and 24 hours after occlusion. Cortical CBF was determined by laser-Doppler flowmetry. Neurological and neuropathological examinations were performed after 72 hours. Neuron-specific enolase, a specific marker for the incidence of neuronal injury, was measured in plasma. The CBF in the ischemic core and periphery, as well as brain temperature and physiological parameters, were not affected by nicardipine during occlusion or reperfusion. However, nicardipine treatment significantly improved motor neurological outcome by 32%, and the infarction and edema volume in the pallium as well as the edema volume in the striatum were significantly reduced by 28%, 37%, and 53%, respectively. Nicardipine also significantly reduced the neuron-specific enolase plasma levels by 50%, 42%, and 59% at 24, 48, and 72 hours after the occlusion, respectively. It is concluded that nicardipine may attenuate focal ischemic brain injury by exerting direct neuroprotective and antiedematous effects that do not depend on CBF.

Systemic physostigmine increases the antinociceptive effect of spinal morphine

In this study we evaluated the antinociceptive effect of concurrent intrathecal (i.t.) and subcutaneous (s.c.) administration of morphine and physostigmine, respectively. The experiments were performed on male Wistar rats. Intrathecal administration of morphine was performed through a catheter implanted in the subarachnoid space. The 'tail-immersion' test was used to measure animals' responses to evoked nociceptive stimuli. Interaction of drugs was analyzed using a dose addition model. Both i.t. (1-5 microg) administration of morphine and s.c. (50-250 microg/kg) administration of physostigmine increased the latencies of nociceptive responses in a dose-dependent manner. Two micrograms of i.t. morphine and 100 microg/kg of s.c. physostigmine demonstrated 31.6 +/- 10.6 and 34.2 +/- 11.4 percentage of maximal possible effect (%MPE), respectively. Simultaneous administration of 1 microg of i.t. morphine and 50 microg/kg of s.c. physostigmine produced a %MPE equal to 84.8 +/- 16.9. Thus, combined administration of 1 microg i.t. morphine and 50 microg/kg s.c. physostigmine resulted in a strong, highly significant antinociceptive effect. This effect was much higher than the effect expected if both drugs acted in an additive manner. Supra-additive interaction observed in this study might be a result of simultaneous activation of different neurotransmitter systems involved in nociceptive processing at the spinal as well as at the supraspinal level of the CNS.

Intraoperative maintenance of tissue perfusion prevents ARDS. Adult Respiratory Distress Syndrome

Patients undergoing prolonged, complex oncological surgery are at increased risk of developing the adult respiratory distress syndrome (ARDS) and other organ failures. Our hypothesis is that maintaining adequate tissue perfusion and oxygenation may prevent tissue hypoxia and acidosis in pulmonary, peripheral, and splanchnic microcirculations. Experimental evidence suggests that the hypoxic, acidotic endothelium stimulates the release of cytokines, kinins, and other mediators. We developed and tested an intraoperative protocol for surgical patients likely to develop ARDS and organ dysfunction; the protocol focuses on the intraoperative period but is not limited to this time. Nitroglycerin and fluids were used to maintain tissue perfusion and prevent tissue hypoxia as reflected by transcutaneous oxygen tension values. In 155 high-risk patients, none developed ARDS. We conclude that maintenance of tissue perfusion and oxygenation in high-risk surgical patients decreases the incidence of ARDS.

Vagus nerve stimulation activates central nervous system structures in epileptic patients during PET H2(15)O blood flow imaging

OBJECTIVE

To determine the central areas of activation by vagal nerve stimulation (VNS) in epilepsy. VNS is a promising neurosurgical method for treating patients with partial and secondary generalized epilepsy. The anti-epileptic mechanism of action from VNS is not well understood.

METHODS

We performed H2(15)O PET blood flow functional imaging on three patients with epilepsy in a vagal nerve stimulation study (E04 Protocol with Cyberonics). The three patients included two that had previous epilepsy surgery but continued to have frequent seizures. Seizure onset was frontal in two patients and bitemporal in the third patient. Twelve PET scans per subject were acquired every 10 minutes with a Siemens 953/A scanner. In 6 stimulus scans, VNS was activated for 60 seconds (2 mA, 30 Hz) commensurate with isotope injection. In 6 control scans no VNS was administered. No clinical seizures were present during any scan. Three way ANOVA with linear contrasts subject, task, repetition) of coregistered images identified significant treatment effects.

RESULTS

The difference between PET with VNS and without revealed that left VNS activated right thalamus (P < 0.0006), right posterior temporal cortex (P < 0.0003), left putamen (P < 0.0002), and left inferior cerebellum (P < 0.0009).

CONCLUSIONS

VNS causes activation of several central areas including contralateral thalamus. Localization to the thalamus suggests a possible mechanism to explain the therapeutic benefit, consistent with the role of the thalamus as a generator and modulator of cerebral activity.

Mechanical malfunction of the Leksell Gamma knife during patient treatment

During the course of a patient treatment with a North American U-type gamma unit, the remote hydraulic valve controlling the direction of couch motion failed to change state. The couch, helmet and patient remained in treatment position after the expiration of treatment time for one of the target shots. No unusual equipment warning indications had been observed prior to the malfunction. The gamma unit was new, having been used to treat approximately 20 patients since it had begun to be used clinically 11 weeks previously. This specific situation was not addressed in our posted Emergency Procedures, which dealt explicitly with loss of electrical power, and loss of hydraulic pressure. In the present case, the hydraulic gauges indicated full pressure. After attempts to disengage the patient remotely proved unsuccessful, personnel entered the room. The table clutch at the foot of the couch was operated to disengage the couch/helmet assembly from its docked position. While this was not mentioned in our emergency procedures, the act had the effect of causing the cobalt-60 sources to be misaligned with the collimator apertures, thereby immediately terminating the patient treatment. This also had the unanticipated effect of substantially reducing radiation leakage exposure rate next to the couch near the tunnel opening. The patient was released from the helmet trunnions using a manufacturer-supplied long-handled special Allen key. The key was used conventionally, to release the trunnion locking mechanism, and also unconventionally to force a separation of a trunnion from the docking slot on the patient head frame. The patient was then removed from the tunnel by sliding out the pad on which she was lying. Anesthesiology personnel accompanied the patient out of the room. The unit functioned properly upon the replacement of the valve by manufacturer service personnel the next day. The patient returned for completion of treatment 1 week later. There were only minor changes to the overall patient dosimetry as a result of the malfunction. Personnel exposures were very low. The malfunction was reported to State authorities, who conducted an investigation, that was in turn followed up by an investigation by the Nuclear Regulatory Commission.

Gamma unit facility: concept genesis, architectural design and practical realization

The physical creation of a gamma unit facility requires the development of a broad-perspective multidisciplinary plan. The primary goal is radiosurgical treatment of intracranial lesions in a functional environment. The practical realization of a facility optimally designed for patient treatment is dependent on factors which include the facility setting, architectural goals, radiation safety requirements, and patient and medical team needs. This necessitates combined intellectual resources from neurosurgery, radiation oncology and physics, anesthesia, radiology, nursing, administration, and architectural and engineering teams. We undertook the development of a gamma unit facility which optimized the ergonomics and efficiency of patient evaluation, care and treatment, given the instrument requirements. This general plan based on our experience can be used for the development of other gamma unit facilities.

Propylene glycol toxicity following continuous etomidate infusion for the control of refractory cerebral edema

Continued elevations in Intracranial Pressure (ICP) following traumatic or ischemic compromise are known to cause markedly increased morbidity and mortality. Because of the side effects of barbiturates including hypotension and prolonged recovery time, the use of shorter-acting anesthetic agents to control ICP has been considered. Etomidate, when administered by continuous infusion, has been shown to decrease cerebral metabolism resulting in a secondary decrease in cerebral blood flow with minimal changes in cerebral perfusion pressure. We initially intended to randomize 20 patients prospectively into a study protocol that would assess the effects of either pentobarbital or the cardioprotective agent etomidate on ICP and cardiac performance. Given the sequelae of the therapy, we were only able to randomize seven patients with cerebral edema refractory to medical management to receive either etomidate or pentobarbital in a blinded fashion. Three patients who received etomidate developed renal compromise (mean low creatinine clearance 41 ml/min, range 37-44 ml/min) which was initially noted at 24 hours. We believed that this represented an adverse effect that was probably related to the study drug and the study was stopped. Each patient received a 0.30 mg/kg IV induction of etomidate and then 0.02 mg/kg/min continuous infusion for 24-72 hours titrated burst suppression. All patients also received dexamethasone 2 mg IV every six hours to prevent the adrenocortical insufficiency that might occur as a consequence of etomidate-induced suppression of cortisol synthesis. Intracranial pressure decreased (mean = 12mmHg) following the initiation of etomidate. Cardiac parameters remained unchanged (cardiac output 4.8 +/- .6 liters/min).(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiac performance enhancement and hypervolemic therapy

This article discusses guidelines the authors have established in managing patients with ruptured intracranial aneurysms and associated vasospasm. These guidelines represent methods of improving cardiac output or the ideal cardiac indices, to improve or maximize cerebral blood flow and potentially improve outcome. The guidelines for hypervolemic therapy for the volume and timing of intravenous fluid administration and the target cardiac performance parameters also are discussed.

Cardiac performance enhancement from dobutamine in patients refractory to hypervolemic therapy for cerebral vasospasm

The use of the beta-agonist dobutamine in combination with hypervolemic preload enhancement of cardiac performance was analyzed in 23 patients who failed to respond to traditional preload enhancement following aneurysmal subarachnoid hemorrhage. The patients ranged in age from 13 to 82 years, and three had a history of cardiac disease. Each patient underwent placement of a flow-directed balloon-tipped catheter and the following measurements were obtained during hyperdynamic therapy: pulmonary artery wedge pressure, central venous pressure, cardiac index, stroke volume index, total peripheral resistance, and left ventricular stroke work index (LVSWI). Mean baseline cardiac function was found to be within normal limits (LVSWI = 47.6 +/- 4.2 gm/min/sq m and cardiac index = 3.30 +/- 0.22 liter/min/sq m). After baseline measurements were recorded, 5% albumin was infused at 300 cc/hr and dobutamine was initiated at a rate of 5 to 10 micrograms/kg/hr. This hyperdynamic therapy with dobutamine in the presence of volume loading resulted in a 52% increase in cardiac index, a 15% increase in LVSWI, and a 21% decrease in total peripheral resistance. The clinical reversal of ischemic symptoms due to subarachnoid hemorrhage was evident in 18 (78%) of the 23 patients.

Management of intraoperative rupture of aneurysm without hypotension

A retrospective analysis was performed on all aneurysms operated on by one of us (SLG) from July 1980 to October 1988 to determine the factors that govern outcome from the intraoperative rupture of aneurysms. A total of 276 consecutive surgical procedures for 317 intracranial aneurysms produced 41 perioperative or intraoperative ruptures for analysis. Five cases were pre-exposure ruptures, 3 of which occurred during anesthetic induction. Four of these patients died, and 1 made a good recovery. Of the remaining 36 cases, outcome was analyzed in terms of the adjuncts used to deal with the intraoperative rupture. There was no statistically significant difference in outcome between those cases in which tamponade was used to control hemorrhage versus temporary clipping; however, those cases in which hypotension was used did less well than those in which it was not used. From October 1986 to October 1988, 108 operations for 132 aneurysms were performed without the use of induced hypotension. There were 16 intraoperative ruptures (14.8%). All 16 of these patients made a good recovery. In the group before 1986, of which there were 20 intraoperative ruptures (of 168 operations, 11.9%), 11 of those 20 patients suffered a permanent deficit or died. We conclude that hypotension may not be a necessary adjunct to the management of intraoperative rupture of aneurysms.

Management of Intraoperative Rupture of Aneurysm without Hypotension

A retrospective analysis was performed on all aneurysms operated on by one of us (SLG); from July 1980 to October 1988 to determine the factors that govern outcome from the intraoperative rupture of aneurysms. A total of 276 consecutive surgical procedures for 317 intracranial aneurysms produced 41 perioperative or intraoperative ruptures for analysis. Five cases were pre-exposure ruptures, 3 of which occurred during anesthetic induction. Four of these patients died, and 1 made a good recovery. Of the remaining 36 cases, outcome was analyzed in terms of the adjuncts used to deal with the intraoperative rupture. There was no statistically significant difference in outcome between those cases in which tamponade was used to control hemorrhage versus temporary clipping; however, those cases in which hypotension was used did less well than those in which it was not used. From October 1986 to October 1988, 108 operations for 132 aneurysms were performed without the use of induced hypotension. There were 16 intraoperative ruptures (14.8%);. All 16 of these patients made a good recovery. In the group before 1986, of which there were 20 intraoperative ruptures (of 168 operations, 11.9%);, 11 of those 20 patients suffered a permanent deficit or died. We conclude that hypotension may not be a necessary adjunct to the management of intraoperative rupture of aneurysms.

Computed imaging stereotaxy: experience and perspective related to 500 procedures applied to brain masses

The evolution of more sophisticated imaging techniques has initiated a renewed interest in stereotactic devices, methods, and applications. The Brown-Roberts-Wells instrument was available to us early in its prototype stage, and this report reviews the first 500 cases using the system at the University of Southern California Medical Center Hospitals. Procedures were undertaken after recognition of apparent structural alterations on imaging studies, with objectives being both diagnostic and therapeutic. Target locations were predominantly within the cerebral centrum-basal ganglia (284 cases) and diencephalic-mesencephalic regions (129 cases). Operative objectives included: histological and microbiological assay, cyst and abscess aspiration, installation of temporary or permanent drainage conduits, point source and colloid base brachytherapy, cerebroscopy and ventriculoscopy with biopsy, aspiration, and excision, and intraoperative vascular localization. Using multiple instrumentation at the target point (741 point placements), we realized procedural objectives in 95.6% of the cases. The mortality was 0.2% and the morbidity was 1%: hematoma, 2 cases; infection, 1 case; increased deficit, 1 case; intraprocedural seizure, 1 case. A specific diagnosis was not obtained in 4.4% (necrosis, 10 cases; inflammatory response, 9 cases; granuloma, 1 case; gliosis, 1 case; diagnostic error, 1 case). Individual guidelines for case selection, technique, institutional requirements, and applications of the method are discussed.(ABSTRACT TRUNCATED AT 250 WORDS)

Nitrous oxide withdrawal reduces intracranial pressure in the presence of pneumocephalus

Nitrous oxide anesthesia has been implicated as contributing to the development of delayed tension pneumocephalus following surgery performed in the sitting position. The authors tested the hypothesis that withdrawal of nitrous oxide anesthesia administered during formation of an intracranial gas cavity would lead to a decrease in intracranial pressure (ICP) as N2O diffuses from the cavity back into the blood. Ten halothane-anesthetized rabbits were prepared for measurement of supracortical ICP and arterial blood pressure (BP) and for intracranial volume alterations via a cisterna magna infusion catheter. Hyperventilation (Paco2 = 28-30 mmHg) and mannitol were used to shrink the brain to accommodate intracranial infusion of either air or lactated Ringer's (LR) solution, which was used to elevate ICP to between 10-15 mmHg from a baseline ICP of 2.1 +/- 2.5 mmHg over a period of 8 to 10 min. Following stabilization at an elevated ICP, inhalation of nitrous oxide (75%) was either initiated or withdrawn (if already present during the induced ICP increase) and the subsequent changes in mean ICP and BP were recorded. Following ICP elevation with LR to 10 +/- 1 mmHg, initiation of 75% N2O administration resulted in no change in ICP and modest increases (P less than 0.05) in BP and cerebral perfusion pressure (CPP = BP - ICP) after 4 min. However, when ICP was raised (to 12 +/- 3.5 mmHg) with intracranial air infusion, subsequent initiation of 75% N2O inhalation caused an abrupt ICP increase to 22.3 +/- 9 mmHg (from control P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Ruptured intracranial aneurysms during pregnancy. A report of four cases

Four patients presented with ruptured intracranial aneurysms during pregnancy. Problems encountered during the management of these cases included delayed diagnosis, obstructive hydrocephalus, cerebral ischemia due to vasospasm and recurrent subarachnoid hemorrhage. Recent advances in the management of ruptured intracranial aneurysms, including early computerized tomographic scanning, intravascular volume expansion and induced hypertension for the management of cerebral vasospasm, and the timely obliteration of the aneurysm are applicable to the subarachnoid hemorrhage patient even if her condition is complicated by pregnancy.

Computed tomographic guidance stereotaxis in the management of lesions of the third ventricular region

The initial management strategies for lesions of the 3rd ventricular region are often controversial. Current techniques for computed tomographic guidance stereotaxis allow accurate access to any intracranial point. A Brown-Roberts-Wells stereotactic system was used as a technical adjunct in the initial management of 42 mass lesions of the 3rd ventricular region. Objectives included biopsy, culture, aspiration, visualization, and installment of drainage conduits. Forty-five point placements were accomplished, and 140 tissue specimens were retrieved without complication. The pathological diagnosis was substantiated in all cases and included lesions of developmental (1 case), neoplastic (31 cases), and infectious (10 cases) origins. Information based on stereotactic assessment provided a rational substrate for the initiation of management, which included craniotomy, cerebrospinal fluid diversion, radiotherapy, chemotherapy, and antibiotic or antiviral therapies. Based on this experience, it is apparent that these methods offer acceptably safe and accurate access to lesions of the entire 3rd ventricular region. Histological or microbiological diagnosis without the need for craniotomy may be readily realized and offers logical guidance for therapeutic strategies. Dependent on the pathological condition, definitive treatment may be achieved.