Neurosurgery
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The technical evolution of cranial base surgery has resulted in approaches that allow more radical surgical extirpation of complex cranial base lesions. Our service has extensively applied these cranial base approaches for lesions of the cranial base. A subgroup of 100 patients who had cranial base tumors involving potential manipulation or sacrifice of carotid arteries underwent 20-minute balloon test occlusions coordinated with vascular assessments consisting of a combination of the following: 1) four-vessel cerebral angiogram with compression studies; 2) occlusion transcranial Doppler ultrasonography; 3) occlusion single-photon emission computed tomography perfusion studies; and 4) xenon-133 cerebral blood flow studies. ⋯ Our experience leads us to believe that no vascular assessment exists today that can predict the occurrence of vascular complications accurately. The current enthusiasm for cranial base surgery must be tempered with the sober reality that management of cerebrovascular anatomy and physiology remain significant limitations. Consideration of potential cerebrovascular complications is paramount to successful outcome and implementation of cranial base surgery.
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In primary malignant brain tumors increased vascularity and marked edema strongly suggest a possible role of the vascular endothelial growth factor/vascular permeability factor (VEGF/VPF). This was confirmed by earlier in situ hybridization studies, by analysis of the expression of the mitogen in different subsets of glioblastoma cells, and by the fact that the VEGF/VPF receptor flt-1 (fms-like tyrosine kinase) is up-regulated in tumor cells in vivo. To assess and quantify the expression of the VEGF/VPF gene and of the receptor gene, 26 surgical specimens of brain tumor tissue from 24 patients were analyzed. ⋯ In addition, using a radioreceptor assay it was possible to detect high VEGF/VPF-like activity in the cyst fluids of brain tumors, indicating the accumulation of the mitogen and permeability factor in brain tumor cysts. Further investigations revealed that astrocytoma and glioblastoma cells in culture express the VEGF/VPF gene and secrete the VEGF/VPF protein, whereas gene expression of the two known VEGF/VPF receptors, kinase insert domain-containing receptor and flt-1, could not be detected. These data support previous reports, which stated that VEGF/VPF acts as a paracrine growth and permeability factor in brain tumors and may contribute to tumor growth by initiating tumor angiogenesis.
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Neurobehavioral outcome after craniocerebral gunshot wounds was evaluated in a prospective, 3-year, longitudinal follow-up of a consecutive case series of 13 children and adolescents. The younger group was composed of seven children, ages 1.5 to 4 years, and the older group contained six children, ages 5 to 14. Outcome measures included the Glasgow Outcome Scale and neuropsychological assessment of intelligence, language, motor, memory, attention, academic achievement, and adaptive behavior. ⋯ Disabilities appear to be at least as severe in our sample after cerebral gunshot wounds as in our studies of severe pediatric closed-head injury. At the time of follow-up, younger children sustaining gunshot wounds had slightly lower intelligence quotient scores and similar receptive language, expressive language, and gross motor scores compared with children with severe closed-head injury. The older gunshot wound patients were significantly more impaired than patients with severe closed-head injuries on measures of adaptive behavior and attention.(ABSTRACT TRUNCATED AT 250 WORDS)
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Quantitative cine-mode magnetic resonance imaging of the craniocervical junction was performed in 17 patients with a Chiari I malformation to evaluate cerebrospinal fluid (CSF) dynamics, including 8 patients who underwent surgery. The cine-mode magnetic resonance images of these patients were compared with those of 12 normal pediatric and adult subjects. The craniocervical junction was imaged by 16 cardiac-gated velocity-encoded images arranged in a cine loop. ⋯ Postoperatively, there was a substantial increase in both the velocity of CSF flow and in the period of caudal CSF flow in the foramen magnum. The postoperative changes mirrored the velocity profiles of the normal subjects. These changes in CSF velocity and direction correlated with a more normal-appearing foramen magnum, a reduction in syrinx size, and an improvement in symptoms.
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In an attempt to evaluate the response of patients who have low admission Glasgow Coma Scale scores (GCS) after a penetrating craniocerebral injury to aggressive management, we evaluated a series of 190 patients with penetrating injuries who presented with a GCS score of 3, 4, or 5 during a 6-year period. Entrance criteria required replicable neurological examinations that were not altered by the presence of hypotension, drugs/toxins, or systemic injury. The surgical patients included 21 patients with an admission GCS score of 3, 24 with an admission GCS score of 4, and 15 with an admission GCS score of 5. ⋯ Five had a Glasgow Outcome Score of 2, five had a Glasgow Outcome Score of 3, and one had a Glasgow Outcome Score of 4. We have devised a prospective model of outcome based on our series in an attempt to predict nonsurvivors at admission (while overpredicting for survivors). The variables most predictive of mortality include admission GCS score and subarachnoid hemorrhage in one model and admission GCS score and pupillary changes in a second, when pupillary response was definitive at admission (P < or = 0.00005).(ABSTRACT TRUNCATED AT 250 WORDS)