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Laligam N. Sekhar, Giuseppe Lanzino, Chandra N. Sen and Spiros Pomonis

✓ Sixteen reconstruction procedures of the third through sixth cranial nerves were carried out in 14 patients during operations on 149 tumors involving the cavernous sinus. A direct end-to-end anastomosis was performed in five nerves, whereas in 11 cases the nerve stumps were bridged by means of an interposing nerve graft. The sixth cranial nerve was most frequently reconstructed (nine cases). In four cases, the fifth nerve or root was repaired. The third nerve was reconstructed in two patients, and the fourth nerve was repaired in only one case.

Recovery of function, either partial or complete, was observed in 13 nerves: the third in two instances, the fourth in one, the fifth in three, and the sixth in seven. No return of function occurred in three nerves. In patients with a successful recovery of cranial nerve function, either binocular function or the cosmetic result was improved. These results suggest that repair of the third through sixth cranial nerves injured during surgery should be pursued in suitable patients.

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Giuseppe Lanzino, Neal F. Kassell, Teresa Germanson, Laura Truskowski and Wayne Alves

✓ Plasma glucose levels were studied in 616 patients admitted within 72 hours after subarachnoid hemorrhage (SAH). Glucose levels measured at admission showed a statistically significant association with Glasgow Coma Scale scores, Botterell grade, deposition of blood on computerized tomography (CT) scans, and level of consciousness at admission. Elevated glucose levels at admission predicted poor outcome. A good recovery, as assessed by the Glasgow Outcome Scale at 3 months, occurred in 70.2% of patients with normal glucose levels (≤ 120 mg/dl) and in 53.7% of patients with hyperglycemia (> 120 mg/dl) (p = 0.002). The death rates for these two groups were 6.7% and 19.9%, respectively (p = 0.001). The association was still maintained after adjusting for age (> or ≤ 50 years) and thickness of clot on CT scans (thin or thick) in the subset of patients who were alert/drowsy at admission. Increased mean glucose levels between Days 3 and 7 also predicted a worse outcome; good recovery was observed in 132 (73.7%) of 179 patients who had normal mean glucose levels (≤ 120 mg/dl) and 160 (49.7%) of 322 who had elevated mean glucose levels (> 120 mg/dl) (p < 0.0001). Death occurred in 6.7% and 20.8% of the two groups, respectively (p < 0.0001). It is concluded that admission plasma glucose levels can serve as an objective prognostic indicator after SAH. Elevated glucose levels during the 1st week after SAH also predict a poor outcome. However, a causal link between hyperglycemia and outcome after delayed cerebral ischemia, although suggested by experimental data, cannot be established on the basis of this study.

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Gail L. Kongable, Giuseppe Lanzino, Teresa P. Germanson, Laura L. Truskowski, Wayne M. Alves, James C. Torner, Neal F. Kassell and the Participants

✓ Female gender is a recognized risk factor for the occurrence of aneurysmal subarachnoid hemorrhage. In the present study the authors analyzed differences in admission characteristics and outcome between 578 women (64%) and 328 men (36%) who were enrolled in a recently completed clinical trial. The female-to-male ratio was nearly 2:1. The women in the study were older than the men (mean age 51.4 years vs. 47.3 years, respectively, p < 0.001). Female patients harbored aneurysms of the internal carotid artery more frequently than male patients (36.8% vs. 18.0%, p < 0.001) and more often had multiple aneurysms (32.4% vs. 17.6%, p < 0.001). On the other hand, anterior cerebral artery aneurysms were more commonly encountered in men (46.1% in men vs. 26.6% in women, p < 0.001). Other baseline prognostic factors were balanced between the gender groups. Surgery was performed equally in both sexes (98%), although the time to operation was shorter for women (mean 3.6 days for women vs. 5.3 days for men, p = 0.0002). In the placebo group, the occurrence of vasospasm was not statistically different between the two groups. Primary causes of death and disability were the same, and favorable outcome rates at 3 months were not statistically different between the genders (69.7% for women vs. 73.4% for men, p = 0.243). The odds of a favorable outcome in women versus one in men were not statistically significant either before or after adjustment for age. These observations lead the authors to suggest that although women are older and harbor more aneurysms, the 3-month outcome for women and men who experience aneurysmal subarachnoid hemorrhage is the same.

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Giuseppe Lanzino, Neal F. Kassell, Teresa P. Germanson, Gail L. Kongable, Laura L. Truskowski, James C. Torner, John A. Jane and Participants

✓ Advanced age is a recognized prognostic indicator of poor outcome after subarachnoid hemorrhage (SAH). The relationship of age to other prognostic factors and outcome was evaluated using data from the multicenter randomized trial of nicardipine in SAH conducted in 21 neurosurgical centers in North America. Among the 906 patients who were studied, five different age groups were considered: 40 years or less, 41 to 50, 51 to 60, 61 to 70, and more than 71 years. Twenty-three percent of the individuals enrolled were older than 60 years of age. Women outnumbered men in all age groups.

Level of consciousness (p = 0.0002) and World Federation of Neurological Surgeons grade (p = 0.0001) at admission worsened with advancing age. Age was also related to the presence of a thick subarachnoid clot (p = 0.0001), intraventricular hemorrhage (p = 0.0003), and hydrocephalus (p = 0.0001) on an admission computerized tomography scan. The rebleeding rate increased from 4.5% in the youngest age group to 16.4% in patients more than 70 years of age (p = 0.002). As expected, preexisting medical conditions, such as diabetes (p = 0.028), hypertension (p = 0.0001), and pulmonary (p = 0.0084), myocardial (p = 0.0001), and cerebrovascular diseases (p = 0.0001), were positively associated with age. There were no age-related differences in the day of admission following SAH, timing of the surgery and/or location, and size (small vs. large) of the ruptured aneurysm.

During the treatment period, the incidence of severe complications (that is, those complications considered life threatening by the reporting investigator) increased with advancing age, occurring in 28%, 33%, 36%, 40%, and 46% of the patients in each advancing age group, respectively (p = 0.0002). No differences were observed in the reported frequency of surgical complications. No age-related differences were found in the overall incidence of angiographic vasospasm; however, symptomatic vasospasm was more frequently reported in the older age groups (p = 0.01). Overall outcome, assessed using the Glasgow Outcome Scale at 3 months post-SAH, was poorer with advancing age (p < 0.001). Multivariate analysis of overall outcome, adjusting for the different prognostic factors, did not remove the age effect, which suggests that the aging brain has a less optimal response to the initial bleeding. Age as a risk factor is a continuum; however, there seems to be a significant increased risk of poor outcome after the age of 60 years.

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Mark E. Shaffrey, Giuseppe Lanzino, M. Beatriz S. Lopes, Richard B. Hessler, Neal F. Kassell and Scott R. Vandenberg

✓ Immature teratomas arising within the central neuraxis are rare neoplasms. These tumors contain diverse cell lineages that retain an embryonal character and display phenotypic differentiation attributed to the three classic germ layers. The clinical management of these lesions is unclear, due in part to their low incidence and to an incomplete understanding of their natural history. Although the potential for phenotypic differentiation and cellular maturation within immature teratomas arising in the gonads is well documented, this has not been described in the intracranial tumors. In the present report, the authors describe two cases of intracranial immature teratomas, one involving the pineal region and the other involving the left frontotemporal lobes, which underwent cellular differentiation and maturation. At initial resection, the tumors from both cases were composed predominantly of primitive neuroepithelial tissue that was admixed with immature and differentiating mesenchymal and epithelial structures. No foci of germinoma, endodermal sinus, choriocarcinoma, or embryonal carcinoma tissue were present. Subsequent resections in both cases revealed an absence of immature tissue. The tumor in Case 1 contained only differentiated epithelial and mesenchymal tissue with no neuroepithelial component, whereas the tumor in Case 2 demonstrated abundant mature neuronal and glial tissue. These two cases from different intracranial sites suggest that spontaneous maturation may be a significant aspect of the natural history of intracranial immature teratomas.

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Robert A. Mericle, Ajay K. Wakhloo, Demetrius K. Lopes, Giuseppe Lanzino, Lee R. Guterman and L. Nelson Hopkins

✓ Guglielmi detachable coil (GDC) treatment for complicated cerebral aneurysms is an attractive option that has become widely accepted in recent years. This technique is usually considered only if the patient harbors an aneurysm that is not a good candidate for surgical clipping. However, the definition of “surgical candidate” varies among institutions, and many patients worldwide are being treated with GDCs as primary therapy. Although most centers currently perform follow-up angiography at 6 months to 1 year, others do not routinely perform it after an initially good result. The authors present a case that indicates longer follow up may be necessary and illustrates some of the pitfalls of GDC treatment.

This 56-year-old man presented to the emergency room with a Hunt and Hess Grade II subarachnoid hemorrhage and was found to have a wide-necked basilar apex aneurysm. Because of associated medical comorbidities, it was decided to treat the aneurysm with endovascular techniques. The patient did well on follow-up angiography at 1 year postprocedure. However, at approximately 2 years follow up, the aneurysm was demonstrated to have dramatically recanalized and regrown, requiring open surgical intervention.

Endovascular coiling was insufficient to treat this aneurysm and complicated definitive surgical management because a large coil mass had been placed in the operative field. It can be inferred from this case that angiographic follow up of these types of lesions may be beneficial up to 2 years after GDC treatment.

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Giuseppe Lanzino, Ajay K. Wakhloo, Richard D. Fessler, Robert A. Mericle, Lee R. Guterman and L. Nelson Hopkins

Results of previous in vitro and in vivo experimental studies have suggested that the placement of a porous stent within the parent artery across the aneurysm neck may hemodynamically uncouple the aneurysm from the parent vessel, leading to thrombosis of the aneurysm. For complex wide-necked aneurysms, a stent may also aid the packing of the aneurysm with Guglielmi detachable coils (GDCs) by acting as a rigid scaffold that prevents coil herniation into the parent vessel. Recently, improved stent system delivery technology has allowed access to the tortuous vascular segments of the intracranial system. The authors report here the intracranial stenting of aneurysms involving different segments of the internal carotid artery (ICA) and the vertebral artery (VA).

Four patients with intracranial aneurysms located at the petrous, cavernous, and paraclinoid segments of the ICA and at the VA proximal to the origin of the posterior inferior cerebellar artery, respectively, were treated since January 1998. In three of these patients, stent placement across the aneurysm neck was followed by GDC placement, accomplished via a microcatheter through stent mesh. In one patient, the aneurysm was treated solely by stenting.

No periprocedural complications were observed, and at follow up, no patient was found to have suffered symptoms referable to aneurysm growth or thromboembolic complications. More than 90% occlusion of the aneurysm was achieved in the three cases treated by stenting and GDC placement. One of these patients underwent 6-month follow-up angiography that did not reveal any in-stent stenosis. In the case treated solely by stent placement, no evidence of aneurysm thrombosis was observed either immediately postprocedure or on follow-up angiography performed 24 hours later.

A new generation of flexible stents can be used to treat intracranial aneurysms in difficult-to-access areas such as the proximal intracranial segments of the ICA or the VA. The stent allows tight coil packing even in the presence of a wide-necked, irregularly shaped aneurysm and may provide an endoluminal matrix for endothelial growth. Although convincing experimental evidence suggests that stent placement across the aneurysm neck may by itself promote intraluminal thrombosis, the role of this phenomenon in clinical practice may be limited at present by the high porosity of currently available stents.