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Marc S. Schwartz, Gregory P. Lekovic, Mia E. Miller, William H. Slattery and Eric P. Wilkinson

OBJECTIVE

Translabyrinthine resection is one of a number of treatment options available to patients with vestibular schwannomas. Though this procedure is hearing destructive, the authors have noted excellent clinical outcomes for patients with small tumors. The authors review their experience at a tertiary acoustic neuroma referral center in using the translabyrinthine approach to resect small vestibular schwannomas. All operations were performed by a surgical team consisting of a single neurosurgeon and 1 of 7 neurotologists.

METHODS

Data from a prospectively maintained clinical database were extracted and reviewed. Consecutive patients with a preoperative diagnosis of vestibular schwannoma that had less than 1 cm of extension into the cerebellopontine angle, operated on between 2008 and 2013, were included. Patents with neurofibromatosis Type 2, previous treatment, or preexisting facial weakness were excluded. In total, 107 patients were identified, 74.7% of whom had poor hearing preoperatively.

RESULTS

Pathologically, 6.5% of patients were found to have a tumor other than vestibular schwannoma. Excluding two malignancies, the tumor control rates were 98.7%, as defined by absence of radiographic disease, and 99.0%, as defined by no need for additional treatment. Facial nerve outcome was normal (House-Brackmann Grade I) in 97.2% of patients and good (House-Brackmann Grade I–II) in 99.1%. Complications were cerebrospinal fluid leak (4.7%) and sigmoid sinus thrombosis (0.9%), none of which led to long-term sequelae.

CONCLUSIONS

Translabyrinthine resection of small vestibular schwannomas provides excellent results in terms of complication avoidance, tumor control, and facial nerve outcomes. This is a hearing-destructive operation that is advocated for selected patients.

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Marc S. Schwartz, Derald E. Brackmann, Eric P. Wilkinson, John L. Go and Felipe Santos

The authors report a case of neurofibromatosis Type 2 presenting with symptoms of trigeminal neuralgia refractory to medical management following placement of an auditory brainstem implant (ABI). Physical examination and history revealed trigeminal neuralgia. A 3D FIESTA (fast imaging employing steady-state acquisition) MR imaging study demonstrated compression of the trigeminal nerve by an ABI cable. After maximal medical therapy, a retrosigmoid microscopic decompression of the trigeminal nerve achieved complete symptom resolution. This is the first report of an ABI cable becoming displaced, resulting in neurovascular compression. This case demonstrates that trigeminal neuralgia can result from nonvascular compression of the trigeminal nerve.

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Eric M. Jackson, Daniel M. Schwartz, Anthony K. Sestokas, Deborah M. Zarnow, N. Scott Adzick, Mark P. Johnson, Gregory G. Heuer and Leslie N. Sutton

Object

Fetal myelomeningocele closure has been shown to be advantageous in a number of areas. In this study, the authors report on neural function in patients who had previously undergone fetal myelomeningocele repair and returned to the authors' institution for further surgery that included intraoperative neurophysiological monitoring.

Methods

The authors retrospectively reviewed data obtained in 6 cases involving patients who underwent fetal myelomeningocele repair and later returned to their institution for spinal cord untethering. (In 4 of the 6 cases, the patients also underwent removal of a dermoid cyst [3 cases] or removal of an epidermoid cyst [1 case] during the untethering procedure.) Records and imaging studies were reviewed to identify the anatomical level of the myelomeningocele as well as the functional status of each patient. Stimulated electromyography (EMG) and transcranial motor evoked potential (tcMEP) recordings obtained during surgery were reviewed to assess the functional integrity of the nerve roots and spinal cord.

Results

During reexploration, all patients had reproducible signals at or below their anatomical level on stimulated EMG and tcMEP recordings. Corresponding to these findings, prior to tethering, all patients had antigravity muscle function below their anatomical level.

Conclusions

All 6 patients had lower-extremity function and neurophysiological monitoring recording signals at or below their anatomical level. These cases provide direct evidence of spinal cord and nerve root conductivity and functionality below the anatomical level of the myelomeningocele, further supporting that neurological status improves with fetal repair.

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Mario Zanaty, Nohra Chalouhi, Robert M. Starke, Shannon W. Clark, Cory D. Bovenzi, Mark Saigh, Eric Schwartz, Emily S. I. Kunkel, Alexandra S. Efthimiadis-Budike, Pascal Jabbour, Richard Dalyai, Robert H. Rosenwasser and Stavropoula I. Tjoumakaris

OBJECT

The factors that contribute to periprocedural complications following cranioplasty, including patient-specific and surgery-specific factors, need to be thoroughly assessed. The aim of this study was to evaluate risk factors that predispose patients to an increased risk of cranioplasty complications and death.

METHODS

The authors conducted a retrospective review of all patients at their institution who underwent cranioplasty following craniectomy for stroke, subarachnoid hemorrhage, epidural hematoma, subdural hematoma, and trauma between January 2000 and December 2011. The following predictors were tested: age, sex, race, diabetic status, hypertensive status, tobacco use, reason for craniectomy, urgency status of the craniectomy, graft material, and location of cranioplasty. The cranioplasty complications included reoperation for hematoma, hydrocephalus postcranioplasty, postcranioplasty seizures, and cranioplasty graft infection. A multivariate logistic regression analysis was performed. Confidence intervals were calculated as the 95% CI.

RESULTS

Three hundred forty-eight patients were included in the study. The overall complication rate was 31.32% (109 of 348). The mortality rate was 3.16%. Predictors of overall complications in multivariate analysis were hypertension (OR 1.92, CI 1.22–3.02), increasing age (OR 1.02, CI 1.00–1.04), and hemorrhagic stroke (OR 3.84, CI 1.93–7.63). Predictors of mortality in multivariate analysis were diabetes mellitus (OR 7.56, CI 1.56–36.58), seizures (OR 7.25, CI 1.238–42.79), bifrontal cranioplasty (OR 5.40, CI 1.20–24.27), and repeated surgery for hematoma evacuation (OR 13.00, CI 1.51–112.02). Multivariate analysis was also applied to identify the variables that affect the development of seizures, the need for reoperation for hematoma evacuation, the development of hydrocephalus, and the development of infections.

CONCLUSIONS

The authors' goal was to provide the neurosurgeon with predictors of morbidity and mortality that could be incorporated in the clinical decision-making algorithm. Control of a patient's risk factors and early recognition of complications may help practitioners avoid the exhaustive list of complications.