T he mechanisms of nonhemorrhagic neurological deterioration in the setting of spinal arteriovenous malformation (AVM) are not well understood. 1–4 In the absence of hemorrhage and/or demonstrated cord compression, the role of urgent surgical intervention is not clear. It has been suggested that surgery might at best arrest neurological deterioration, but would not be expected to reverse it. 1, 6 We report a case of spinal AVM with rapid nonhemorrhagic neurological deterioration to dense paraplegia following lumbar puncture, with favorable response to
Issam A. Awad and Gene H. Barnett
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.
Narendra Nathoo, Frederick K. Lautzenheiser and Gene H. Barnett
G eorge Washington Crile, pioneer surgeon, physiologist, innovator, inventor, soldier, and the principal founder of the Cleveland Clinic Foundation, lived during the golden era of surgery, when the discipline was evolving from a crude and chancy art to a specialized applied science. In addition to being Ohio's first neurosurgeon, Crile is notable for other pioneering works, such as the investigation of surgical shock and its prevention, the emphasis on the importance of monitoring vital physiological signs during surgery, the administration of the first
Narendra Nathoo, Marc R. Mayberg and Gene H. Barnett
surgical practice, with a special interest in thyroid problems. The first event that impacted his life and career was an unexpected vacancy on Frazier's service that coincided with the beginning of Gardner's mandatory 3-month rotation in neurosurgery in April 1926. This was created by the decision of Frazier's assistant, Temple Fay, to spend 2 years on William G. Spiller's neurology service. Rotation on Frazier's service had become unpopular among the interns because of its demanding nature and the Chief's stern demeanor. Gardner's plan was to practice general surgery
Case report and review of the literature
Kene Ugokwe, Narendra Nathoo, Richard Prayson and Gene H. Barnett
✓ Ancient change in a schwannoma is a histological variant typically found in longstanding tumors. Histologically, the tumor has biphasic features typical of a schwannoma with evidence of degenerative changes that may complicate diagnosis. The authors report on a 23-year-old man with no features of neurofibromatosis who presented with headaches, blurred vision, and ataxic gait. Magnetic resonance imaging demonstrated a rim-enhancing lesion in the cerebellopontine angle with displacement of brainstem structures and no supratentorial hydrocephalus. Using a lateral suboccipital approach together with image guidance and intraoperative neurophysiological monitoring, a gross-total macroscopic excision was performed. At surgery, the tumor was found to arise from the inferior division of the trigeminal nerve. The final histological diagnosis was schwannoma with ancient change. Note that ancient change in schwannomas is a histological variant thought to result from degenerative changes in longstanding tumors. To the authors' knowledge, this is the first independent report of this histological variant in an intracranial schwannoma.
Gene H. Barnett, Donald W. Kormos, Charles P. Steiner and Joe Weisenberger
reference frame to the patient's head during both neuroimaging and the surgical procedure, is logistically cumbersome, and does not provide the surgeon with real-time identification of intracranial structures during the operative procedure. We present an alternative system that responds to these problems. Materials and Methods Reference Fiducials In lieu of an external frame, landmarks (“fiducials”) that can be identified both on the neuroimaging study, whether computerized tomography (CT) scan or magnetic resonance (MR) image, and at surgery are required
Gene H. Barnett, David W. Miller and Joseph Weisenberger
also brought to light the limitations and restrictions imposed by IGFSs, fostering a movement toward the development of surgical navigation systems (SNSs) not reliant on reference frames. 3, 5, 18, 24, 44, 52–55, 60 Surgical navigation systems (that is, frameless stereotactic systems) were initially developed for, and perfected in, craniotomy surgery, eventually yielding results comparable or superior to frame-based techniques. 4, 5, 17, 19 In our own experience encompassing more than 600 craniotomies and 250 spine operations, SNSs based on sonic or optical
Amer Khalil, Alejandro M. Spiotta and Gene H. Barnett
response to hypercarbia via the tracheostomy could be assessed. We were asked to evaluate the patient for neurological prognosis. This determination was crucial with respect to planning for potential complex, staged reconstructive surgeries. As the clinical examination was so greatly limited, we resorted to imaging and electrical recording studies. Intervention A noncontrast brain CT study was normal. Intracranial pressure monitoring was deemed infeasible given the extent of potential soft-tissue infection and colonization of the face, scalp, and exposed bone with
Symeon Missios, Kimon Bekelis and Gene H. Barnett
. Because LITT is a minimally invasive technique that can deliver high-precision focal thermal ablation, and it has been explored as a new approach to epilepsy surgery. Wellmer and colleagues 55 reported on the use of stereotactic radiofrequency thermocoagulation for the ablation of focal cortical dysplasia in 2 patients with pharmacoresistant epilepy. Both patients were seizure free at 12 and 5 months, and no deficits were encountered. While the technique does not rely on laser thermal ablation, it shares similarities with LITT, including the stereotactic placement of a
Matthew M. Grabowski, Pablo F. Recinos, Amy S. Nowacki, Jason L. Schroeder, Lilyana Angelov, Gene H. Barnett and Michael A. Vogelbaum
may underestimate the full extent of tumor burden. 10 , 23 Extent of resection is not an ideal measure of the success of surgery, as it does not convey a direct indication of the residual disease burden that must be addressed by medical therapies (i.e., radiation therapy and chemotherapy). The biological impact of EOR is likely to be strongly dependent upon the preoperative tumor volume (PTV). That is, a near-total resection of a very large tumor may leave behind more tumor mass than a subtotal resection of a small tumor, and yet the proposed relationship between