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Govindaraju Lakshmi Prasad, Manish Singh Sharma, Shashank S. Kale, Deepak Agrawal, Manmohan Singh and Bhawani Shankar Sharma

OBJECTIVE

Of the intracranial schwannomas, those arising from the vestibular nerves are the most common. Abducens nerve (AN) schwannomas are very rare, and there is limited literature on their optimal management. Therapeutic options include surgery and/or stereotactic radiosurgery. The aim of this study was to evaluate the role of Gamma Knife radiosurgery (GKRS) in these sixth cranial nerve (CN) schwannomas.

METHODS

The authors performed a retrospective analysis of patients who had undergone GKRS for intracranial tumors at their institute in the period from 2003 to 2010. Inclusion criteria were as follows: isolated AN paresis on presentation, a lesion along the course of the sixth CN, and imaging features characteristic of a schwannoma. Patients with other CN deficits and neurofibromatosis Type 2 were excluded. Symptomatic improvement was defined as the resolution of or an improvement in diplopia noted on a subjective basis or as an improvement in lateral eyeball excursion noted objectively on follow-up. A reduction in tumor volume by at least 20%, as noted by comparing the pre- and post-GKRS images, was deemed significant.

RESULTS

Six patients with a mean age of 37.1 years (range 17–55 years) underwent primary GKRS. There were 2 prepontine cistern, 3 cavernous sinus, and 1 cisterno-cavernous tumor. The mean duration of symptoms was 6.1 months (range 3–12 months). The mean tumor volume was 3.3 cm3 (range 1.5–4.8 cm3). The mean tumor margin radiation dose was 12.5 Gy (range 12–14 Gy), while the median margin dose was 12 Gy (50% isodose line). The median number of isocenters used was 5 (range 4–8). The brainstem received an average 8.35-Gy radiation dosage (range 5.5–11 Gy). The mean follow-up duration was 44.3 months (range 24–78 months). Symptoms remained stable in 1 patient, improved in 3, and resolved in 2 (total improvement 83%). Magnetic resonance imaging at the last follow-up showed a stable tumor size in 3 patients (50%) and a reduction in the other 3. Thus, the tumor control rate achieved was 100%. No new CN deficits were noted.

CONCLUSIONS

Abducens nerve schwannomas are rare intracranial tumors. They can be cavernous, cisternal, or cisterno-cavernous in location. Excellent tumor control rates and symptomatic improvement can be achieved with GKRS, which appears to be a safe and effective, minimally invasive modality for the treatment of such lesions. Therefore, it is reasonable to consider GKRS as the initial treatment of choice for this rare pathology. Long-term follow-up will be essential for further recommendations.

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Akash Mishra, Deepak Agrawal, Deepak Gupta, Sumit Sinha, Guru D. Satyarthee and Pankaj K. Singh

OBJECT

Spondyloptosis represents the most severe form of spondylolisthesis, which usually follows high-energy trauma. Few reports exist on this specific condition, and the largest series published to date consists of only 5 patients. In the present study the authors report the clinical observations and outcomes in a cohort of 20 patients admitted to a regional trauma center for severe injuries including spondyloptosis.

METHODS

The authors performed a retrospective chart review of patients admitted with spondyloptosis at their department over a 5-year period (March 2008–March 2013). Clinical, radiological, and operative details were reviewed for all patients.

RESULTS

In total, 20 patients with spondyloptosis were treated during the period reviewed. The mean age of the patients was 27 years (range 12–45 years), and 17 patients were male (2 boys and 15 men) and 3 were women. Fall from height (45%) and road traffic accidents (35%) were the most common causes of the spinal injuries. The grading of the American Spinal Injury Association (ASIA) was used to assess the severity of spinal cord injury, which for all patients was ASIA Grade A at the time of admission. In 11 patients (55%), the thoracolumbar junction (T10–L2) was involved in the injury, followed by the dorsal region (T1–9) in 7 patients (35%); 1 patient (5%) had lumbar and 1 patient (5%) sacral spondyloptosis. In 19 patients (95%), spondyloptosis was treated surgically, involving the posterior route in all cases. In 7 patients (37%), corpectomy was performed. None of the patients showed improvement in neurological deficits. The mean follow-up length was 37.5 months (range 3–60 months), and 5 patients died in the follow-up period from complications due to formation of bedsores (decubitus ulcers).

CONCLUSIONS

To the authors' best knowledge, this study was the largest of its kind on traumatic spondyloptosis. Its results illustrate the challenges of treating patients with this condition. Despite deformity correction of the spine and early mobilization of patients, traumatic spondyloptosis led to high morbidity and mortality rates because the patients lacked access to rehabilitation facilities postoperatively.

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Deepak Agrawal, M.Ch., Paul Steinbok and D. Douglas Cochrane

Object

A number of studies have shown good short-term cosmetic outcomes following surgery for isolated sagittal craniosynostosis. Whether the improvement in head shape persists in the longer term is less clear. The aim of this study was to investigate the long-term anthropometric outcomes following surgery for isolated sagittal craniosynostosis.

Methods

Records were retrospectively reviewed for children with isolated sagittal synostosis who underwent surgical revision between 1987 and 2000. Only children who underwent surgery before 8 months of age and for whom serial anthropometric data (skull width, skull length, and cephalic index) were available were included in the study. The operative procedure consisted of vertex and parietal craniectomies involving removal of the sagittal suture and a 1.5- to 2.5-cm piece of adjacent parietal bone on each side as well as bilateral parietal barrel-stave osteotomies.

Ninety cases satisfied the eligibility criteria. The mean age of the patients at surgery was 5 months (range 1.9–7.5 months). The mean preoperative cephalic index was 66.78. The follow-up period ranged from 1.8 to 167 months (mean 39.6 months). In 24 cases, the follow-up period was longer than 36 months. Eighteen (75%) and five (20.8%) of these 24 cases were followed up for longer than 5 and 10 years, respectively. The mean increase in cephalic index at the last follow up was 8.69% (p < 0.0001). The maximum improvement in the cephalic index occurred within 6 months of surgery, at which point it had improved by a mean of 11.1% (p < 0.0001). The cephalic index remained increased throughout the follow-up period, with a mean change of –1.84% (standard deviation, 4.28%; 99% confidence interval –3.33 to –0.37%) from the first postoperative to the final measurement.

Conclusions

Surgery for isolated sagittal craniosynostosis leads to a significant improvement in the cephalic index, which is most marked in the early postoperative period. Improvement in the cephalic index is still present after prolonged follow up.

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Deepak Agrawal, Paul Steinbok and D. Douglas Cochrane

Object

Data from animal studies have shown that in experimentally induced craniosynostosis, removal of the involved calvaria results in the formation of new calvaria with time, and sutures redevelop in their normal anatomical positions. However, the pattern of suture reformation following surgery in humans with craniosynostosis remains ill-defined. The aim of this study was to determine the pattern of postoperative suture reformation in children who have undergone surgery for isolated sagittal synostosis and assess possible factors related to suture reformation.

Methods

Records were retrospectively reviewed for 42 consecutive infants who had surgery for isolated sagittal synostosis between 1987 and 2000 and for whom postoperative skull radiographs were available. The radiographs were evaluated for sagittal suture morphology and patency of the coronal and lambdoid sutures. Surgery involved at a minimum 1) a vertex craniectomy, characterized by removal of the sagittal suture and a 1.5- to 2.5-cm piece of adjacent parietal bone with the attached pericranium bilaterally, and 2) parietal osteotomies and/or craniectomies.

The median age at surgery was 3.9 months (range 1.9–7.6 months). The mean duration of follow up was 32.2 months (range 6–144 months). The sagittal suture had reformed in only seven (16.7%) of the children at follow up. In the other 35 (83.3%), the craniectomized bone defects had reossified without any part of the sagittal suture being visible on the radiographs.

Conclusions

There is a very low incidence of suture reformation in children after surgery for isolated sagittal craniosynostosis. Genetic predisposition, inclusion of undiagnosed syndromic patients, and current operative techniques may be some of the factors responsible for the low incidence of suture reformation seen in this series.

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Deepak Agrawal, Naveen K. Gowda, Chandra S. Bal, Manish Pant and Ashok Kumar Mahapatra

Object

The authors sought to correlate the finding of medial temporal hypoperfusion (MTH) demonstrated on single photon emission computerized tomography (SPECT) with pediatric persistent postconcussion syndrome (PPCS) and to ascertain its usefulness in routine clinical practice.

Methods

Thirty consecutive children with minor head injury and features of PPCS underwent SPECT scanning within 72 hours of injury. Those children having MTH on SPECT were included in the test group (14 patients), and the remaining 16 children comprised the control group. At the end of a 3-month period SPECT scanning was repeated and the incidence of PPCS was assessed clinically in both groups.

Repeated SPECT scanning at 3 months revealed persisting MTH in 13 children (93%) in the test group; no child developed MTH in the control group. Twelve children were found to have PPCS in the MTH group compared with only two in the control group, and this was highly statistically significant (relative risk 6.86 [95% confidence interval 1.84–25.51], p = 0.0003).

Conclusions

There exists significant MTH in pediatric patients with PPCS, which would imply that medial temporal lobe damage (involving the hippocampus and related structures) may occur after minor head injury and could be responsible for the symptoms of PPCS observed in this group of patients. Brain SPECT scans may thus help in the early identification of children prone to develop PPCS, and serial SPECT scanning may serve as a platform for testing the efficacy of various neurobehavioral and pharmacological interventions in these patients.

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Deepak Agrawal, Naveen K. Gowda, Chandra S. Bal, Manish Pant and Ashok Kumar Mahapatra

Object. The authors sought to correlate the finding of medial temporal hypoperfusion (MTH) demonstrated on single photon emission computerized tomography (SPECT) with pediatric persistent postconcussion syndrome (PPCS) and to ascertain its usefulness in routine clinical practice.

Methods. Thirty consecutive children with minor head injury and features of PPCS underwent SPECT scanning within 72 hours of injury. Those children having MTH on SPECT were included in the test group (14 patients), and the remaining 16 children comprised the control group. At the end of a 3-month period SPECT scanning was repeated and the incidence of PPCS was assessed clinically in both groups.

Repeated SPECT scanning at 3 months revealed persisting MTH in 13 children (93%) in the test group; no child developed MTH in the control group. Twelve children were found to have PPCS in the MTH group compared with only two in the control group, and this was highly statistically significant (relative risk 6.86 [95% confidence interval 1.84–25.51], p = 0.0003).

Conclusions. There exists significant MTH in pediatric patients with PPCS, which would imply that medial temporal lobe damage (involving the hippocampus and related structures) may occur after minor head injury and could be responsible for the symptoms of PPCS observed in this group of patients. Brain SPECT scans may thus help in the early identification of children prone to develop PPCS, and serial SPECT scanning may serve as a platform for testing the efficacy of various neurobehavioral and pharmacological interventions in these patients.