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Arnd Doerfler, Michael Forsting, Wolfgang Reith, Christian Staff, Sabine Heiland, Wolf-Rüdiger Schäbitz, Rüdiger von Kummer, Werner Hacke and Klaus Sartor

Acute ischemia in the complete territory of the carotid artery may lead to massive cerebral edema with raised intracranial pressure and progression to coma and death due to uncal, cingulate, or tonsillar herniation. Although clinical data suggest that patients benefit from undergoing decompressive surgery for acute ischemia, little data about the effect of this procedure on experimental ischemia are available. this article the authors present results of an experimental study on the effects of decompressive craniectomy performed at various time points after endovascular middle cerebral artery (MCA) occlusion in rats.

Focal cerebral ischemia was induced in 68 rats using an endovascular occlusion technique focused on the MCA. Decompressive cranioectomy was performed in 48 animals (in groups of 12 rats each) 4, 12, 24, or 36 hours after vessel occlusion. Twenty animals (control group) were not treated by decompression craniectomy. The authors used the infarct volume and neurological performance at Day 7 as study endpoints.

Although the mortality rate in the untreated group was 35%, none of the animals treated by decompressive craniectomy died (mortality 0%). Neurological behavior was significantly better in all animals treated by decompressive craniectomy, regardless of whether they were treated early or late. Neurological behavior and infarction size were significantly better in animals treated very early by decompressive craniectomy (4 hours) after endovascular MCA occlusion (p less than 0.01); surgery performed at later time points did not significantly reduce infarction size.

The results suggest that use of decompressive craniectomy in treating cerebral ischemia reduces mortality and significantly improves outcome. If performed early after vessel occlusion, it also significantly reduces infarction size. By performing decompressive craniectomy neurosurgeons will play a major role in the management of stroke patients.

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Myung-Hyun Kim, Jun-Hyeok Song, Sung-Hak Kim, Dong-Bin Park and Kyu-Man Shin

The development of less invasive methods to evacuate intracerebral hematomas (ICHs) has improved outcome in patients with traumatic brain injury. Eighteen patients with ICHs underwent surgery via one of two methods: stereotactic endoscopic removal (SER) or stereotactic catheter drainage (SCD). The outcome results were then compared. The patient population was composed of 11 men and seven women with a mean age of 53.3 years (range 33-81 years), all suffering from ICH in the basal ganglia. The mean hematoma volume was 34.4 ml (range 23-105 ml). All patients had major neurological deficits, but showed no sign of transtentorial herniation.

Ten patients underwent SCD and eight had SER. All procedures were performed within 24 hours of insult. After local anesthesia was induced in the patient, an intracranial pressure (ICP) monitoring catheter and an Otzuki cannula were placed through separate burr holes in the skull. Using the SER technique, the ICH was removed using suction and forceps through the side window of the cannula until the ICP had decreased significantly. Hemostasis was attained by lesioning with a Nd-YAG laser. In the SCD procedure, we placed a silicone catheter into the hematoma to drain it and then added urokinase. The hematoma was drained for 3 to 5 days in the SER method and 7 to 10 days in the SCD method. Rebleeding occurred in one of the early cases in which we used the SER procedure. At follow-up evaluation, the mortality rate was 13% in the SER group and 10% in the SCD group. The patients in whom outcome was most improved from these treatments were those who had been admitted with an impaired level of consciousness.

Stereotactic catheter drainage is a precise, safe, and brief procedure with a very low rebleeding rate, but its outcome effect was more delayed than other procedures. Stereotactic endoscopic removal can easily replace SCD, with a similar mortality rate. Both procedures can be accomplished under direct visualization so as to eliminate any undesirable event or outcome.

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Christopher L. Taylor, Zhong Yuan, Warren R. Selman, Robert A. Ratcheson and Alfred A. Rimm

The risk of disability and death and the cost of medical care are particularly high for patients with aneurysmal subarachnoid hemorrhage (SAH) who are 65 years of age or older. A retrospective analysis of 47,408 Medicare patients treated over an 8-year period was performed to determine whether a relationship exists between the mortality rate and surgical volume for older patients with SAH. The mortality rate, length of stay in the hospital, and cost of treatment for patients with SAH in California and New York were also compared. The mortality rate was 14.3% for patients with SAH who were 65 years old or older and who were treated surgically in hospitals in which an average of five or more craniotomies were performed per year; in hospitals averaging between one and five craniotomies annually the mortality rate was 18.4%; and in those averaging less than one such operation per year the rate was 20.5% (trend p = 0.01). There was no difference in the mortality rate for patients in California versus the rate for those in New York. Surgically and medically treated patients, respectively, left the hospital an average of 6.7 and 5.1 days sooner in California than in New York. The unadjusted average reimbursement from Medicare to hospitals for surgically treated patients averaged $1468 more in New York than in California (p < 0.0001), but was equivalent for medically treated patients in the two states. The mortality rate in older patients who are treated surgically for SAH may be inversely correlated with the annual number of craniotomies performed for SAH in patients 65 years of age or older at a given institution. Hospital stays for patients with SAH are significantly shorter in California than in New York.

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Introduction Harold L. Rekate M.D. 2 1997 2 2 I 10.3171/foc.1997.2.2.3 FOC.1997.2.2.3 Mortality rates, hospital length of stay, and the cost of treating subarachnoid hemorrhage in older patients: institutional and geographical differences Christopher L. Taylor M.D. Zhong Yuan M.D. Warren R. Selman M.D. Robert A. Ratcheson M.D. Alfred A. Rimm Ph.D. 2 1997 2 2 E1 10.3171/foc.1997.2.2.1 FOC.1997.2.2.1 Cerebral blood flow as a predictor of outcome following traumatic brain injury Daniel F. Kelly M.D. Neil A. Martin M.D. Rouzbeh Kordestani M.D. George Counelis

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Uwe M. H. Schrell, Michael G. Rittig, Marc Anders, Franklin Kiesewetter, Rolf Marschalek, Uwe H. Koch and Rudolf Fahlbusch

Meningiomas, which invade intracranial bone structures and the adjacent connective tissue, are frequently unresectable because of their aggressive and recalcitrant growth behavior. They have a high recurrence rate, and in approximately 10% of these tumors there is an increased risk of malignancy. Significant morbidity and mortality rates associated with recurrent meningiomas demand nonsurgical approaches. To date, adjuvant hormonal treatment has not proven beneficial. The anticancer drug hydroxyurea was therefore tested for its potential use in the treatment of meningiomas.

Early-passaged cell cultures were established from 20 different meningiomas. The addition of 5 X 10−4 and 10−3 M hydroxyurea over a period of 5 to 9 days resulted in a remarkable decrease in cell proliferation and even blocked tumor cell growth when compared with untreated cells. A significant arrest of meningioma cell growth in the S phase of the cell cycle was revealed on DNA flow cytometry.

Electron micrographs of hydroxyurea-treated tumor cells showed ultrastructural features consistent with apoptosis, and light microscopy demonstrated DNA fragmentation by in situ DNA strand break labeling. Short-term treatment of meningioma cell cultures with hydroxyurea for 24 to 48 hours resulted in discrete oligonucleosomal fragments (DNA ladder), another characteristic sign of apoptosis. In addition to the in vitro studies, tissue from five different meningiomas was transplanted into nude mice followed by treatment with 0.5 mg/g body weight hydroxyurea over 15 days. In situ DNA strand break labeling demonstrated DNA fragmentation in distinct regions with different tumor cell densities in all hydroxyurea-treated meningioma transplants.

These data provide evidence that hydroxyurea is a powerful inhibitor of meningioma cell growth, most likely by causing apoptosis in the tumor cells. Thus, hydroxyurea may be a suitable chemotherapeutic agent for the long-term treatment of unresectable or semi- to malignant meningiomas, or for preventing recurrent growth of meningiomas after resection.

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Rudolf Fahlbusch, Jürgen Honegger, Werner Paulus, Walter Huk and Michael Buchfelder

The surgical management of 168 consecutive patients harboring craniopharyngiomas treated between January 1983 and April 1997 is described. In 148 patients undergoing initial (primary) surgery, the pterional approach was most frequently used (39.2%) followed by the transsphenoidal approach (23.6%). For large retrochiasmatic craniopharyngiomas, the bifrontal interhemispheric approach was used increasingly over the pterional approach and led to improved surgical results. Total tumor removal was accomplished in 45.7% of transcranial and 85.7% of transsphenoidal procedures. The main reasons for incomplete removal were attachment and/or infiltration of the hypothalamus, major calcifications, and attachment to vascular structures. The success rate in total tumor removal was inferior in the cases of tumor recurrence. The operative mortality rate in transcranial surgery was 1.1% in primary cases and 10.5% in cases of tumor recurrence. No patient died in the group undergoing transsphenoidal surgery. The rate of recurrence-free survival after total removal was 86.9% at 5 years and 81.3% at 10 years. In contrast, the 5-year recurrence-free survival rate was only 48.8% after subtotal removal and 41.5% after partial removal. Following primary surgery, the actuarial survival rate was 92.7% at 10 years, with the best results after complete tumor removal. At last follow up, 117 (79%) of 148 patients who underwent primary surgery were independent and without impairment.

Total tumor removal while avoiding hazardous intraoperative manipulation provides favorable early results and a high rate of long-term control in craniopharyngiomas.

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Kaushik Das, Ahmed Rawanduzy and William T. Couldwell

The goals of surgery in unstable thoracic fractures or tumors involving the thoracic spine are neural decompression, correction of deformity, and stabilization. Several different approaches can be used to achieve these goals. The anterior, combined anterior and posterior, and more recently thoracoscopic approaches are well described in the literature and are extremely effective in achieving the goals mentioned. However, they do carry with them significant morbidity and mortality rates in patients who are elderly, who have associated medical problems, or for whom there are contraindications to thoracic surgery. The authors believe the posterolateral approach is a viable alternative that is reasonably well tolerated in this select patient population. One can achieve circumferential neural decompression as well as anterior and posterior arthrodesis through a single incision. Most neurosurgeons are familiar with the anatomical landmarks and technical steps in the posterolateral approach, and the authors believe it is a less invasive method that can be especially useful and should not be overlooked in this subgroup of patients.

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Neill M. Wright and Carl Lauryssen

Object

The 847 active members of the American Association of Neurological Surgeons/Congress of Neurological Surgeons (AANS/CNS) Section on Disorders of the Spine and Peripheral Nerves were surveyed to quantitate the risk of vertebral artery (VA) injury during C1-2 transarticular screw placement.

Methods

This retrospective study elicited the number of patients treated with transarticular screws, the number of screws placed, the incidence of VA injury and subsequent neurological deficit, and the management of known or suspected VA injury.

Two hundred thirteen (25.1%) of the 847 surgeons responded. One hundred one respondents (47.4%) had placed a total of 2492 C1-2 transarticular screws in 1318 patients. Thirty-one patients (2.4%) had known VA injuries and an additional 23 patients (1.7%) were suspected of having injuries. However, only two (3.7%) of the 54 patients with known or suspected VA injuries exhibited subsequent neurological deficits and only one (1.9%) died from bilateral VA injury. Other iatrogenic complications included dural tears, screw fractures, screw breakout, fusion failure, infection, and suboccipital numbness.

Conclusions

Including both known and suspected cases, the risk of VA injury was 4.1% per patient or 2.2% per screw inserted. The risk of neurological deficit from VA injury was 0.2% per patient or 0.1% per screw, and the mortality rate was 0.1%. The choice of management of intraoperative VA injuries was evenly divided between placing the patient under observation and initiating immediate postoperative angiography with possible balloon occlusion.

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Sarel J. Vorster and Gene H. Barnett

Although surgical resection of brain tumors has been performed for over a century, complications still occur with distressing frequency.

The authors propose a simple preoperative grading scheme to assess surgical risk for resection of primary and secondary intraaxial supratentorial brain tumors.

The authors retrospectively reviewed the clinical records, neuroimaging studies, and outcomes of 224 surgeries performed in 207 patients from January 1993 to December 1995 at the Cleveland Clinic Foundation Brain Tumor Center. Subsequently, they considered and statistically analyzed multiple variables related to the patients and their lesions. Surgical risk was defined as any complication occurring within 30 days postoperatively, and was divided into transient operative complications, transient medical complications, and new sustained neurological deficits. Length of stay was also recorded. The overall incidence of complications was 10.6% and the mortality rate was 2.7%, with a median hospital stay of 3 days. Patient age greater than 60 years (p < 0.001), preoperative Karnofsky Performance Scale scores of 50 or less (p < 0.03), previous irradiation (p < 0.001), tumor location in eloquent regions (p < 0.03), and depth of tumor invasion (p < 0.001) independently predicted complicated outcome or increased length of stay. Finally, the authors derived a simple five-tier grading scheme in which these patient risk factors are added together to obtain a grade of I to V that corresponds to outcome and length of hospital stay.

This grading scheme may be used to identify patients at higher risk and facilitate comparison of results between institutions and individual surgeons.

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Ziya L. Gokaslan, Julie E. York, Garrett L. Walsh, Ian E. McCutcheon, Frederick F. Lang, Joe B. Putnam Jr., David M. Wildrick, Stephen G. Swisher, Dima Abi-Said and Raymond Sawaya

Anterior approaches to the spine for the treatment of spinal tumors have gained acceptance; however, in most published reports, patients with primary, metastatic, or chest wall tumors involving cervical, thoracic, or lumbar regions of the spine are combined. The purpose of this study was to provide a clear perspective of results that can be expected in patients who undergo anterior vertebral body resection, reconstruction, and stabilization for spinal metastases that are limited to the thoracic region.

Outcome is presented for 72 patients with metastatic spinal tumors who were treated by transthoracic vertebrectomy at The University of Texas M. D. Anderson Cancer Center. The predominant primary tumors included renal cancer in 19 patients, breast cancer in 10, melanoma or sarcoma in 10, and lung cancer in nine patients. The most common presenting symptoms were back pain, which occurred in 90% of patients, and lower-extremity weakness, which occurred in 64% of patients. All patients underwent transthoracic vertebrectomy, decompression, reconstruction with methylmethacrylate, and anterior fixation with locking plate and screw constructs. Supplemental posterior instrumentation was required in seven patients with disease involving the cervicothoracic or thoracolumbar junction, which was causing severe kyphosis. After surgery, pain improved in 60 of 65 patients. This improvement was found to be statistically significant (p < 0.001) based on visual analog scales and narcotic analgesic medication use. Thirty-five of the 46 patients who presented with neurological dysfunction improved significantly (p < 0.001) following the procedure. Thirty-three patients had weakness but could ambulate preoperatively. Seventeen of these 33 regained normal strength, 15 patients continued to have weakness, and one patient was neurologically worse postoperatively. Of the 13 preoperatively nonambulatory patients, 10 could walk after surgery and three were still unable to walk but showed improved motor function. Twenty-one patients had complications ranging from minor atelectasis to pulmonary embolism. The 30-day mortality rate was 3%. The 1-year survival rate for the entire study population was 62%.

These results suggest that transthoracic vertebrectomy and spinal stabilization can improve the quality of life considerably in cancer patients with spinal metastasis by restoring or preserving ambulation and by controlling intractable spinal pain with acceptable rates of morbidity and mortality.