✓Granular cell tumors of the ulnar nerve are extremely rare, with only two cases previously reported in the English literature. The author presents a case of granular cell tumor of the ulnar nerve, in which the tumor was resected and the nerve was repaired with a nerve graft. The histopathological characteristics, imaging findings, and clinical data regarding these tumors are reviewed, and based on all the available evidence, a new treatment paradigm is proposed, which differs from that used in the earlier reported cases and takes into account the reported rate of tumor recurrence after incomplete resection.
Gavin A. Davis
Gavin A. Davis
Gavin A. Davis and Simon Knight
Pancoast tumors are aggressive bronchogenic lesions of the lung apex that are rapidly fatal if untreated. Modern treatment includes induction chemotherapy and radiotherapy prior to resection, but many authors also resect the T-1 nerve root (with or without the C-8 nerve root and the lower trunk of the brachial plexus) as part of the therapy, causing significant loss of hand function in many patients. The current authors determined whether a different approach allowing preservation of the brachial plexus and hand function could be adopted without compromising patient survival. An extensive historical review of Pancoast tumors is presented as a baseline for clinical comparison.
Five patients harboring Pancoast tumors with brachial plexus involvement underwent surgery performed by both a neurosurgeon and thoracic surgeon. In all cases the tumor was resected from the brachial plexus using neurolysis while preserving the C-8 and T-1 nerve roots and lower trunk of the brachial plexus.
One patient died 3 years posttreatment; the other four patients remain alive and well 2 to 5 years postoperatively. Hand function improved or remained normal in all four survivors, with postoperative intrinsic hand muscle function being Louisiana State University Medical Center Grade 5 in each patient. These results (2-year survival rate of 100%) compare favorably with the Southwest Oncology Group Data (overall 2-year survival rate of 55%; 70% in patients who had undergone complete resection). With a minimum 2-year follow-up, 80% of patients remained alive and well, with normal hand function.
Although this patient series is small, the findings are extremely encouraging and suggest that the described treatment paradigm preserves survival as well as hand function in patients with Pancoast tumors.
Gavin A. Davis and Ian H. Cox
The etiology of intraneural ganglia has been debated for centuries, and only recently a unifying theory has been proposed. The incidence of tibial nerve intraneural ganglia is restricted to the occasional case report, and there are no reported cases of these lesions in children. While evidence of the unifying theory for intraneural ganglia of the common peroneal nerve is strong, there are only a few reports describing the application of the theory in the tibial nerve. In this report the authors examine tibial nerve intraneural ganglia at the ankle and knee in an adult and a child, respectively, and describe the clinical utility of incorporating the unifying (articular) theory in the management of tibial intraneural ganglia in adults and children.
Cases of tibial intraneural ganglion cysts were examined clinically, radiologically, operatively, and histologically to demonstrate the application of the unified (articular) theory for the development of these cysts in adults and children.
Two patients with intraneural ganglion cysts of the tibial nerve were identified: an adult with an intraneural ganglion cyst of the tibial nerve at the tarsal tunnel and a child with an intraneural ganglion cyst of the tibial nerve at the knee. In each case, preoperative MR imaging demonstrated the intraneural cyst and its connection to the adjacent joint via the articular branch to the subtalar joint and superior tibiofibular joint. At surgery the articular branch was identified and resected, thus disconnecting the tibial nerve intraneural cyst from the joint of origin.
These cases detail the important features of intraneural ganglion cysts of the tibial nerve and document the clinical utility of incorporating the unifying (articular) theory for the surgical management of tibial intraneural ganglia in adults and children.
Gavin A. Davis, Gregory J. Fitt, Renate M. Kalnins, and L. Anne Mitchell
Chow Huat Chan, Richard G. Bittar, Gavin A. Davis, Renate M. Kalnins, and Gavin C. A. Fabinyi
Resection of dysembryoplastic neuroepithelial tumor (DNET) is thought to result in favorable seizure outcome, but long-term follow-up data are scarce. The authors present a review of 18 patients who underwent surgical removal of a DNET: 12 via temporal lobectomy and six via lesionectomy.
The mean long-term follow up was 10.8 years (median 10.4 years, range 7.8 to 14.8 years), and results obtained during this time period were compared with previously reported short-term (mean 2.7 years) seizure outcome data. In the current study, 66.7% patients had an Engel Class I outcome and 55.6% had an Engel Class IA outcome compared with 77.8% and 55.6%, respectively. Temporal lobectomy (Engel Class I, 83.3%; Engel Class IA, 66.7%) led to a better seizure outcome than lesionectomy (Engel Classes I and IA, 33.3%). Two patients (11.1%) required repeated operation and both had an incomplete lesionectomy initially.
Results indicated that complete resection of a DNET leads to a favorable seizure outcome, with epilepsy cure in those who had experienced early postoperative seizure relief. Long-term seizure outcome after surgery is predictable based on the result of short-term follow up.
Franz E. Babl, Mark D. Lyttle, Natalie Phillips, Amit Kochar, Sarah Dalton, John A. Cheek, Jeremy Furyk, Jocelyn Neutze, Silvia Bressan, Amanda Williams, Stephen J. C. Hearps, MBiostat, Ed Oakley, Gavin A. Davis, Stuart R. Dalziel, and Meredith L. Borland
Current clinical decision rules (CDRs) guiding the use of CT scanning in pediatric traumatic brain injury (TBI) assessment generally exclude children with ventricular shunts (VSs). There is limited evidence as to the risk of abnormalities found on CT scans or clinically important TBI (ciTBI) in this population. The authors sought to determine the frequency of these outcomes and the presence of CDR predictor variables in children with VSs.
The authors undertook a planned secondary analysis on children with VSs included in a prospective external validation of 3 CDRs for TBI in children presenting to 10 emergency departments in Australia and New Zealand. They analyzed differences in presenting features, management and acute outcomes (TBI on CT and ciTBI) between groups with and without VSs, and assessed the presence of CDR predictors in children with a VS.
A total of 35 of 20,137 children (0.2%) with TBI had a VS; only 2 had a Glasgow Coma Scale score < 15. Overall, 49% of patients with a VS underwent CT scanning compared with 10% of those without a VS. One patient had a finding of TBI on CT scanning, with positive predictor variables on CDRs. This patient had a ciTBI. No patient required neurosurgery. For children with and without a VS, the frequency of ciTBI was 2.9% (95% CI 0.1%–14.9%) compared with 1.4% (95% CI 1.2%–1.6%) (difference 1.5% [95% CI −4.0% to 7.0%]), and TBI on CT 2.9% (95% CI 0.1%–14.9%) compared with 2.0% (95% CI 1.8%–2.2%) (difference 0.9%, 95% CI −4.6% to 6.4%).
The authors’ data provide further support that the risk of TBI is similar for children with and without a VS.
Franz E. Babl, Vanessa C. Rausa, Meredith L. Borland, Amit Kochar, Mark D. Lyttle, Natalie Phillips, Yuri Gilhotra, Sarah Dalton, John A. Cheek, Jeremy Furyk, Jocelyn Neutze, Silvia Bressan, Gavin A. Davis, Vicki Anderson, Amanda Williams, Ed Oakley, Stuart R. Dalziel, Louise M. Crowe, and Stephen J. C. Hearps
Children with concussion frequently present to emergency departments (EDs). There is limited understanding of the differences in signs, symptoms, and epidemiology of concussion based on patient age. Here, the authors set out to assess the association between age and acute concussion presentations.
The authors conducted a multicenter prospective observational study of head injuries at 10 EDs in Australia and New Zealand. They identified children aged 5 to < 18 years, presenting with a Glasgow Coma Scale score of 13–15, presenting < 24 hours postinjury, with no abnormalities on CT if performed, and one or more signs or symptoms of concussion. They extracted demographic, injury-related, and signs and symptoms information and stratified it by age group (5–8, 9–12, 13 to < 18 years).
Of 8857 children aged 5 to < 18 years, 4709 patients met the defined concussion criteria (5–8 years, n = 1546; 9–12 years, n = 1617; 13 to < 18 years, n = 1546). The mean age of the cohort was 10.9 years, and approximately 70% of the patients were male. Sport-related concussion accounted for 43.7% of concussions overall, increasing from 19.1% to 48.9% to 63.0% in the 5–8, 9–12, and 13 to < 18 years age groups. The most common acute symptoms postinjury were headache (64.6%), disorientation (36.2%), amnesia (30.0%), and vomiting (27.2%). Vomiting decreased with increasing age and was observed in 41.7% of the 5–8 years group, 24.7% of the 9–12 years group, and 15.4% of the 13 to < 18 years group, whereas reported loss of consciousness (LOC) increased with increasing age, occurring in 9.6% in the 5–8 years group, 21.0% in the 9–12 years group, 36.7% in the 13 to < 18 years group, and 22.4% in the entire study cohort. Headache, amnesia, and disorientation followed the latter trajectory. Symptom profiles were broadly similar between males and females.
Concussions presenting to EDs were more sports-related as age increased. Signs and symptoms differed markedly across age groups, with vomiting decreasing and headache, LOC, amnesia, and disorientation increasing with increasing age.