✓ Acute pulmonary edema after a large air embolus occurring during neurosurgery is a recognized phenomenon. The authors describe the course of a 76-year-old man who presented with noncardiogenic pulmonary edema shortly after undergoing resection of a high convexity meningioma. Transthoracic Doppler sonography, however, showed no evidence of a large intraoperative emboli; the evidence for ongoing but low-magnitude air embolus included visualization of bone aspiration of irrigant before bone-edge waxing, transient intraoperative declines in end-tidal CO2 tension, and an increase of the fraction of inspired oxygen to maintain adequate saturation after removal of the craniotomy flap. There was no hemodynamic instability noted. The airspace disease was self-limited and resolved on supportive treatment after approximately 1 week, as would be expected for pulmonary edema caused by a single large intravenous air embolus. The authors present this case as the first report of pulmonary edema resulting from low-level air embolus occurring during craniotomy. This situation may go unrecognized intraoperatively but can cause the same significant postoperative morbidity as larger, more easily identified air emboli.
David M. Frim, Lisa Wollman, Allison B. Evans and Robert G. Ojemann
Christopher S. Ogilvy, Roberto C. Heros, Robert G. Ojemann and Paul F. New
✓ Eight cases of histopathologically proven arteriovenous malformations (AVM's) which were not visualized on angiography are presented. As is typical with these lesions, most of the patients in this series presented with hemorrhage, seizures, or episodic or progressive neurological symptoms suggestive of a neoplasm. The diagnosis of angiographically occult AVM was highly suspected preoperatively in each case based on the combination of computerized tomography (CT) and magnetic resonance (MR) findings. The CT scans in all cases showed moderately hyperdense lesions which enhanced mildly or moderately in a nonhomogeneous pattern with administration of contrast material. The MR image showed one or more bright areas interspersed with areas of low or absent signal peripherally or centrally on both T1- and T2-weighted images. The AVM was totally excised in seven patients and partially excised in one patient, with favorable results in all. The clinical management and differential diagnosis of angiographically occult AVM's are discussed. In patients with a clinical course and radiological studies suggestive of an occult AVM, removal of the lesion, if accessible, should be performed in order to rule out a neoplasm and prevent subsequent hemorrhage and progression of symptoms.
Roberto C. Heros, Gerard M. Debrun, Robert G. Ojemann, Pierre L. Lasjaunias and Pierre J. Naessens
✓ A patient presenting with progressive paraparesis was found to have a spinal arteriovenous fistula at the T3–4 vertebral level. The lesion consisted of a direct communication of the anterior spinal artery with a very distended venous varix that drained mostly superiorly to the posterior fossa and simulated a posterior fossa arteriovenous malformation (AVM) on vertebral angiography. The patient was treated by surgical ligation of the fistula through an anterior transthoracic approach. He deteriorated abruptly on the 4th postoperative day, probably because of retrograde thrombosis of the enlarged anterior spinal artery. Over the next few months, he improved to the point of being able to walk with crutches. He has also regained sphincter control.
The different types of spinal AVM's are reviewed. Our case does not fit into any of these groups. A new category, Type IV, is proposed to designate direct arteriovenous fistulas involving the intrinsic arterial supply of the spinal cord.
Douglas C. Miller, Robert G. Ojemann, Karl H. Proppe, Barry D. McGinnis and Hermes C. Grillo
✓ A patient with a histologically benign intracranial meningioma was found, at the time of initial presentation, also to have a pulmonary tumor. Fine-needle aspiration cytology of the lung mass was consistent with metastatic meningioma. When resected, the pulmonary tumor was found to be histologically benign. The patient has remained well and disease-free for 28 months. Only four other patients with apparently benign metastasizing meningiomas have been described previously.
Brian D. Beyerl, Robert G. Ojemann, Kenneth R. Davis, E. Tessa Hedley-Whyte and Marc R. Mayberg
✓ A case of cervical diastematomyelia in an adult is reported. The patient first noted sensory and motor symptoms at 34 years of age after two episodes of cervical trauma. Metrizamide computerized tomography myelography of the cervical spine and cord showed the region of diastematomyelia and revealed a spur containing both bone and fat tissue projecting into the spinal canal and cord. The spur arose from the laminae and spinous processes of C-2 and C-3, and was successfully excised. Postoperatively, the patient's deficits gradually improved. The literature concerning adult cervical diastematomyelia is reviewed.
David N. Louis, Allan J. Hamilton, Raymond A. Sobel and Robert G. Ojemann
✓ A sphenoid-wing meningioma in a 60-year-old woman was accompanied by elevated serum carcinoembryonic antigen (CEA) levels, which returned to normal after removal of the tumor. Light microscopic examination revealed a secretory meningioma containing numerous pseudopsammoma bodies and a prominent vascular pattern. Immunohistochemical analysis showed the tumor cells and pseudopsammoma bodies to be CEA-positive. This case illustrates the possibility that secretory meningioma may be associated with clinically detectable secretion of CEA. The report also documents the rare occurrence of elevated serum CEA in a primary benign intracranial tumor.
Jeffrey G. Ojemann, Robert L. Grubb, Michael Kyriakos and Kim B. Baker
✓ This 52-year-old woman developed crystal deposition disease involving the cervical vertebrae. She presented with symptomatic spinal cord compression secondary to extensive calcified lesions in the posterior elements of the cervical spine. Surgical decompression with posterior fusion was performed. Histological examination showed hardened deposits of calcium carbonate involving the soft tissue, and dissolution of the vertebral bone trabeculae. There was no inflammatory response to these deposits. One year postoperatively the patient developed severe pulmonary disease associated with the collagen-vascular disorder, scleroderma (calcinosis, Raynaud's phenomenon, esophageal hypomotility, sclerodactyly, and telangiectasia [CREST] syndrome). Calcium carbonate deposition disease represents an unusual clinical entity that is possibly associated with scleroderma or other collagen-vascular diseases, and it is distinct from ligamentum flavum calcification, calcium pyrophosphate deposition disease, and hydroxyapatite deposition disease.
Jeffrey G. Ojemann, T. S. Park, Robert Komanetsky, Richard A. A. Day and Bruce A. Kaufman
✓ The authors investigated the efficacy of anal sphincter electromyography (EMG) in identifying the lower sacral roots during selective dorsal rhizotomy. In nine children undergoing selective dorsal rhizotomy for cerebral palsy (CP) spasticity, direct electrical stimulation of the L1—S5 dorsal and ventral roots was performed while monitoring EMG responses from the anal sphincter and lower-extremity muscles. Anal sphincter activation was seen with stimulation of lumbosacral roots at many levels. Stimulation of dorsal and ventral roots gave anal sphincter EMG responses in 100% of the dorsal and ventral roots from L-4 and caudally. Only at the L-1 level did a minority of nerve roots have anal sphincter response to stimulation. Patterns of extremity muscle and sphincter activation specific to the S3–5 roots, namely anal sphincter activation without activation of other muscle groups, were found in only five (22%) of 23 roots stimulated. The pattern of stimulation responses in the majority of S3–5 roots indicated that the pathophysiology of lower-extremity spasticity in CP may involve the anal sphincter and does not spare the lower sacral roots. Thus, this study indicates that electrophysiological mapping alone, without anatomical identification, cannot be used to identify the lower sacral roots during selective dorsal rhizotomy for CP spasticity, and it proposes a model for investigation of associated bowel and bladder symptoms.
Part 2: Clinical applications
James B. Macon, Charles E. Poletti, William H. Sweet, Robert G. Ojemann and Nicholas T. Zervas
✓ In 27 patients undergoing laminectomy, spinal cord function was monitored by epidural bipolar recordings of conducted spinal somatosensory evoked potentials (SEP's) across the laminectomy site, with calculation of spinal conduction velocity (CV). In control cases without myelopathy, the CV remained relatively constant (± 3%) even during prolonged operations, despite markedly changing levels of anesthesia. Acute CV changes were detected intraoperatively in three cases: these patients displayed improvement after extramedullary (Case 1) and intramedullary decompression (Case 2), and deterioration after direct unilateral dorsal column injury (Case 3). These intraoperative CV alterations correlated postoperatively with changes in the neurological examination. Although a unilateral lesion confined to the dorsal column abolished the ipsilateral SEP in Case 3, complete anterior quadrant lesions did not consistently change the CV (Case 4). This further suggests that the SEP is generated entirely by ipsilateral dorsal column activation. Accurate measurement of this dorsal column conduction velocity across the operative field provides a very sensitive means of monitoring spinal cord function during operations for neurosurgical spinal lesions.
E. Andrew Stevens, Alexander K. Powers, Thomas A. Sweasey, Stephen B. Tatter and Robert G. Ojemann
The authors describe a method of harvesting autologous pericranium for duraplasty in patients with Chiari malformation Type I (CM-I) that avoids excessive exposure or a second incision. Nonautologous dural grafts have been associated with numerous complications including hemorrhage, bacteria and virus transmission, fatal Creutzfeldt-Jakob disease transmission, foreign body reaction, systemic immune response, excessive scarring, slower healing, premature graft dissolution, and wound dehiscence. Autogenous tissues have the advantage of being nonimmunogenic, nontoxic, readily available, and inexpensive. Pericranium is a preferred substrate because it is flexible, strong, and easily sutured for a watertight closure. Current literature supports the use of autogenous pericranium for dural grafting in CM-I procedures, but has heretofore failed to provide a method of harvest that avoids the complications associated with a larger exposure or second incision. The authors offer a simple alternative technique for using local pericranium in duraplasty for CM-I or other posterior fossa abnormalities.