✓ The use of cadaveric human dura has been critical in the repair of dural defects since the dawn of neurosurgery. Reports in the literature of immune response to this type of graft have been extremely rare. Two patients are presented who received cadaveric dural implants with resulting meningeal signs and cerebrospinal fluid eosinophilia several weeks after surgery. Peripheral eosinophilia was present in one patient. The signs and symptoms resolved temporarily during corticosteroid therapy and permanently upon removal of the offending grafts. These cases illustrate that an immune-type reaction can occur with significant morbidity in patients receiving cadaveric dural grafts. A proposed mechanism for this response is discussed.
Report of two cases
Cargill H. Alleyne Jr. and Daniel L. Barrow
Angela Viers, Marshall B. Allen Jr. and Cargill H. Alleyne Jr.
Dr. George W. Smith is credited with developing the Smith-Robinson procedure, the automatic drill, the vessel-encircling aneurysm clip, and treatment of tic douloureux with stilbamidine. His contributions to neurosurgery were unfortunately truncated by his untimely death. This article highlights his career and his contributions.
Khoi D. Nguyen, Ehizele Osehobo and Cargill H. Alleyne Jr.
Scott Y. Rahimi, John H. Brown, Samuel D. Macomson, Michael A. Jensen and Cargill H. Alleyne Jr.
✓ Cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) is a disease process for which the lack of effective treatments has plagued neurosurgeons for decades. Historically, successful treatment after SAH in the acute setting was often followed by a rapid, uncontrollable deterioration in the subacute interval. Little was known regarding the nature and progression of this condition until the mid-1800s, when the disease was first described by Gull. Insight into the origin and natural history of cerebral vasospasm came slowly over the next 100 years, until the 1950s. Over the past five decades our understanding of cerebral vasospasm has expanded exponentially. This newly discovered information has been used by neurosurgeons worldwide for successful treatment of complications associated with vasospasm. Nevertheless, although great strides have been made toward elucidating the causes of cerebral vasospasm, a lasting cure continues to elude experts and the disease continues to wreak havoc on patients after aneurysmal SAH.
M. Neil Woodall, Melissa McGettigan, Ramon Figueroa, James R. Gossage and Cargill H. Alleyne Jr.
Hereditary hemorrhagic telangiectasia (HHT) is a hereditary disorder characterized by mucocutaneous telangiectasias, frequent nosebleeds, and visceral arteriovenous malformations (AVMs). Few reports have outlined the prevalence of the various cerebral vascular malformations found in patients with HHT. The authors set out to define the prevalence of cerebral vascular malformations in a population of HHT patients who underwent imaging with 3-T imaging (MRI/MR angiography [MRA]) of the brain.
A retrospective review of prospectively collected data was carried out using a database of 372 HHT patients who were seen and examined at the Georgia Regents University HHT Center and screened with 3-T MRI/MRA. Data were tabulated for numbers and types of vascular malformations in this population.
Arteriovenous malformations were identified in 7.7%, developmental venous anomalies in 4.3%, and cerebral aneurysms in 2.4% of HHT patients. The HHT AVMs tended to be supratentorial, small, and cortical in this series, findings consistent with other recent studies in the literature. An arteriovenous fistula, cavernous malformation, and capillary telangiectasia were identified in 0.5%, 1%, and 1.9% of HHT patients, respectively.
Few studies have investigated the prevalence of the various vascular malformations found in HHT patients screened with 3-T MRI/MRA of the brain. Hereditary hemorrhagic telangiectasia AVMs are more likely to be multiple and have a tendency toward small size and cortical location. As such, they are often treated using a single-modality therapy.
Scott Y. Rahimi, Cargill H. Alleyne Jr., Eric Vernier, Mark R. Witcher and John R. Vender
Patients undergoing craniotomies have traditionally received opiates with acetaminophen for the management of their postoperative pain. The use of narcotic pain medications can be costly, decrease rates of early postoperative ambulation, lengthen hospital stays, and alter a patient's neurological examination. The use of alternative pain medications such as tramadol may benefit patients by resolving many of these issues.
The authors conducted a randomized, blinded prospective study to evaluate the efficacy of alternative pain management strategies for patients following craniotomies. Fifty patients were randomly assigned either to a control group who received narcotics and acetaminophen alone or an experimental group who received tramadol in addition to narcotic pain medications (25 patients assigned to each group).
The control group was noted to have statistically significant higher visual analog scale pain scores, an increased length of hospital stay, and increased narcotic use compared with the tramadol group. The narcotics and acetaminophen group also had increased hospitalization costs when compared with the tramadol group.
The use of scheduled atypical analgesics such as tramadol in addition to narcotics with acetaminophen for the management of postoperative pain after craniotomy may provide better pain control, decrease the side effects associated with narcotic pain medications, encourage earlier postoperative ambulation, and reduce total hospitalization costs.
Cargill H. Alleyne Jr., C. Michael Cawley, George G. Shengelaia and Daniel L. Barrow
Object. The blood supply of the lower spinal cord is heavily dependent on the artery of Adamkiewicz, which characteristically originates from one of the thoracolumbar segmental arteries. The aforementioned artery is of enormous clinical, surgical, and radiological importance, and the goal of this study was to elucidate the course and branches of the segmental artery that gives rise to this important vessel.
Methods. In this cadaveric, microsurgical anatomical study, the authors investigate and describe the course and branches of the artery of Adamkiewicz and the segmental branch from which it ultimately originates. A review of the literature is provided.
Conclusions. By documenting the microsurgical anatomy of these important vessels, this study facilitates an understanding of the anatomy that will aid in treatment planning for surgery of various lesions in this area.
Cargill H. Alleyne Jr., C. Michael Cawley, George G. Shengelaia and Daniel L. Barrow
The blood supply of the lower spinal cord is heavily dependent on the artery of Adamkiewicz, which characteristically originates from one of the thoracolumbar segmental arteries. The aforementioned artery is of enormous clinical, surgical, and radiological importance, and the goal of this study was to elucidate the course and branches of the segmental artery that gives rise to this important vessel.
In this cadaveric, microsurgical anatomical study, the authors investigate and describe the course and branches of the artery of Adamkiewicz and the segmental branch from which it ultimately originates. A review of the literature is provided.
By documenting the microsurgical anatomy of these important vessels, this study facilitates an understanding of the anatomy that will aid in treatment planning for surgery of various lesions in this area.
Melanie D. King, D. Jay McCracken, F. Marlene Wade, Steffen E. Meiler, Cargill H. Alleyne Jr. and Krishnan M. Dhandapani
Intracerebral hemorrhage (ICH) is associated with significant morbidity and mortality. Acute hematoma enlargement is an important predictor of neurological injury and poor clinical prognosis; but neurosurgical clot evacuation may not be feasible in all patients and treatment options remain largely supportive. Thus, novel therapeutic approaches to promote hematoma resolution are needed. In the present study, the authors investigated whether the curry spice curcumin limited neurovascular injury following ICH in mice.
Intracerebral hemorrhage was induced in adult male CD-1 mice by intracerebral administration of collagenase or autologous blood. Clinically relevant doses of curcumin (75–300 mg/kg) were administered up to 6 hours after ICH, and hematoma volume, inflammatory gene expression, blood-brain barrier permeability, and brain edema were assessed over the first 72 hours. Neurological assessments were performed to correlate neurovascular protection with functional outcomes.
Curcumin increased hematoma resolution at 72 hours post-ICH. This effect was associated with a significant reduction in the expression of the proinflammatory mediators, tumor necrosis factor–α, interleukin-6, and interleukin-1β. Curcumin also reduced disruption of the blood-brain barrier and attenuated the formation of vasogenic edema following ICH. Consistent with the reduction in neuroinflammation and neurovascular injury, curcumin significantly improved neurological outcome scores after ICH.
Curcumin promoted hematoma resolution and limited neurological injury following ICH. These data may indicate clinical utility for curcumin as an adjunct therapy to reduce brain injury and improve patient outcome.
Melanie D. King, Melissa D. Laird, Sangeetha Sukumari Ramesh, Patrick Youssef, Basheer Shakir, John R. Vender, Cargill H. Alleyne Jr. and Krishnan M. Dhandapani
Subarachnoid hemorrhage (SAH) is a devastating neurological injury associated with significant patient morbidity and death. Since the first demonstration of cerebral vasospasm nearly 60 years ago, the preponderance of research has focused on strategies to limit arterial narrowing and delayed cerebral ischemia following SAH. However, recent clinical and preclinical data indicate a functional dissociation between cerebral vasospasm and neurological outcome, signaling the need for a paradigm shift in the study of brain injury following SAH. Early brain injury may contribute to poor outcome and early death following SAH. However, elucidation of the complex cellular mechanisms underlying early brain injury remains a major challenge. The advent of modern neuroproteomics has rapidly advanced scientific discovery by allowing proteome-wide screening in an objective, nonbiased manner, providing novel mechanisms of brain physiology and injury. In the context of neurosurgery, proteomic analysis of patient-derived CSF will permit the identification of biomarkers and/or novel drug targets that may not be intuitively linked with any particular disease. In the present report, the authors discuss the utility of neuroproteomics with a focus on the roles for this technology in understanding SAH. The authors also provide data from our laboratory that identifies high-mobility group box protein-1 as a potential biomarker of neurological outcome following SAH in humans.