✓ Studies in 28 traumatized cats showed the following acute changes after spinal cord compression in the cord segment below the trauma: 1) increase in size of the spinal cord evoked potential; 2) increase in size of the electrospinogram; and 3) increase in frequency of the electrospinogram.
Glenn Morrison, Ronald J. Lorig, Jerald S. Brodkey and Frank E. Nulsen
David I. Sandberg, John Ragheb, Catalina Dunoyer, Sanjiv Bhatia, Greg Olavarria and Glenn Morrison
In this study the authors review the outcomes in pediatric patients who presented with seizures and underwent resection of dysembryoplastic neuroepithelial tumors (DNETs). The authors focus on the diagnostic evaluation and surgical techniques that facilitate gross–total tumor resection and subsequent freedom from seizures.
Eighteen patients between the ages of 1 month and 13 years who presented with seizures underwent resection of DNETs between January 1992 and December 2004. Preoperative evaluation included magnetic resonance (MR) imaging and interictal scalp electroencephalography (EEG) in all patients, functional MR imaging in eight patients, video monitoring with ictal scalp EEG in 12 patients, interictal single-photon emission computerized tomography (SPECT) scanning in one patient, and ictal SPECT scanning in two patients. Thirteen patients underwent one-stage procedures, whereas five underwent two-stage procedures (implantation of monitoring electrodes followed by tumor resection), either for functional language mapping (three patients) or due to inconclusive preoperative data (two patients). Intraoperative electrocorticography (ECoG) was performed in 17 patients and led to resection of the cerebral cortex beyond the tumor margins in 10 of them. According to operative reports, gross–total tumor resections were achieved in all patients, but one child had minimal residual tumor on postoperative MR images that has remained stable. The only surgical complication was a transient third cranial nerve palsy. Over a median follow-up duration of 1.6 years, all patients are seizure free and without radiographically detected tumor recurrence.
Dysembryoplastic neuroepithelial tumors are a highly treatable cause of epilepsy in children. Excellent rates of complete tumor resection and seizure control with minimal morbidity can be attained using intraoperative ECoG and two-stage surgical procedures when appropriate.
Report of three cases
Stacey Quintero Wolfe, Luisa Cervantes, Greg Olavarria, Carole Brathwaite, John Ragheb and Glenn Morrison
✓Desmoplastic fibromas are rare bone tumors that have been reported in the adult skull but rarely in that of children. Although desmoplastic fibromas of the pediatric skull are uncommon, their similarity to benign skull lesions and their locally aggressive nature make them an important part of the differential diagnosis. Local recurrence is common after curettage alone but complete resection appears to be curative. Close follow up of incompletely resected lesions is essential. The authors detail three cases of pediatric desmoplastic fibromas of the skull and discuss diagnosis and treatment.
Glenn Morrison, William M. Hegarty, Charles C. Brausch, Theodore J. Castele and Rorert J. White
✓ A woman with a fusiform aneurysm of a persistent trigeminal artery sustained a subarachnoid hemorrhage and presented with hypalgesia in the distribution of the maxillary and mandibular nerves. The first successful direct operative treatment of this rare aneurysm is reported.
Aria Fallah, Alexander G. Weil, Samir Sur, Ian Miller, Prasanna Jayakar, Glenn Morrison, Sanjiv Bhatia and John Ragheb
Pediatric brain tumors may be associated with medically intractable epilepsy for which surgery is indicated. The authors sought to evaluate the efficacy of epilepsy surgery for seizure control in pediatric patients with brain tumors.
The authors performed a retrospective review of consecutive patients undergoing resective epilepsy surgery related to pediatric brain tumors at Miami Children’s Hospital between June 1986 and June 2014. Time-to-event analysis for seizure recurrence was performed; an “event” was defined as any seizures that occurred following resective epilepsy surgery, not including seizures and auras in the 1st postoperative week. The authors analyzed several preoperative variables to determine their suitability to predict seizure recurrence following surgery.
Eighty-four patients (47 males) with a mean age (± standard deviation) of 8.7 ± 5.5 years (range 0.5–21.6 years) were included. The study included 39 (46%) patients with gliomas, 20 (24%) with dysembryoplastic neuroepithelial tumors (DNETs), 14 (17%) with gangliogliomas, and 11 (13%) with other etiologies. Among the patients with gliomas, 18 were classified with low-grade glioma, 5 had oligodendroglioma, 6 had uncategorized astrocytoma, 3 had pilocytic astrocytoma, 3 had pleomorphic xanthoastrocytoma, 3 had glioblastoma, and 1 had gliomatosis cerebri. Seventy-nine (94.0%) resections were guided by intraoperative electrocorticography (ECoG). The mean time (± standard deviation) to seizure recurrence was 81.8 ± 6.3 months. Engel Class I outcome was achieved in 66 (78%) and 63 (75%) patients at 1 and 2 years’ follow-up, respectively. Patients with ganglioglioma demonstrated the highest probability of long-term seizure freedom, followed by patients with DNETs and gliomas. In univariate analyses, temporal location (HR 1.75, 95% CI 0.26–1.27, p = 0.171) and completeness of resection (HR 1.69, 95% CI 0.77–3.74, p = 0.191) demonstrated a trend toward a longer duration of seizure freedom.
ECoG-guided epilepsy surgery for pediatric patients with brain tumors is highly effective. Tumors located in the temporal lobe and those in which a complete ECoG-guided resection is performed may result in a greater likelihood of long-term seizure freedom.
Sanjiv Bhatia, Faiz Ahmad, Ian Miller, John Ragheb, Glenn Morrison, Prasanna Jayakar and Michael Duchowny
Refractory status epilepticus (RSE) is a life-threatening neurological emergency associated with high morbidity and mortality. Affected patients often require prolonged intensive care and can suffer multiple complications. Surgical intervention to control RSE is rarely used but can obviate the risks of prolonged seizures and intensive care treatment. Authors of the present study analyzed their experience with the surgical management of patients suffering from RSE.
The Epilepsy Surgery Database at Miami Children's Hospital was reviewed for patients who had undergone surgery for RSE. Clinical presentation, electrophysiological profile, radiological data, surgical details, and postoperative course were evaluated.
Between 1990 and 2012, 15 patients underwent surgery for uncontrolled seizures despite high-dose medical suppressive therapy. The mean preoperative duration of status epilepticus was 8 weeks. Ictal SPECT and FDG-PET imaging in conjunction with intraoperative electrophysiological studies helped to outline the extent of resection. Surgical intervention controlled seizures in all patients and facilitated the transition out of intensive care. Adverse events related to a prolonged intensive care unit stay included sepsis and respiratory complications. Four patients had worsened neurological function, developing hemiparesis and dysphasia. There was no operative mortality.
Surgical intervention can successfully control refractory partial status epilepticus, prevent associated morbidity, and decrease intensive care unit stay. Ictal SPECT and PET are valuable in guiding resection.
David Benglis Jr., Derek Covington, Ritwik Bhatia, Sanjiv Bhatia, Mohamed Samy Elhammady, John Ragheb, Glenn Morrison and David I. Sandberg
The natural history of untreated Chiari malformation Type I (CM-I) is poorly defined. The object of this study was to investigate outcomes in pediatric patients with CM-I who were followed up without surgical intervention.
The authors retrospectively reviewed 124 cases involving patients with CM-I who presented between July 1999 and July 2008 and were followed up without surgery. The patients ranged in age from 0.9 to 19.8 years (mean 7 years). The duration of follow-up ranged from 1.0 to 8.6 years (mean 2.83 years). Imaging findings, symptoms, and findings on neurological examinations were noted at presentation and for the duration of follow-up.
The mean extent of tonsillar herniation at presentation was 8.35 mm (range 5–22 mm). Seven patients had a syrinx at presentation. The syrinx size did not change in these patients on follow-up imaging studies. No new syrinxes developed in the remaining patients who underwent subsequent imaging. The total number of patients with presenting symptoms was 81. Of those 81 patients, 67 demonstrated symptoms that were not typical of CM-I. Of the 14 patients with symptoms attributed to CM-I, 9 had symptoms that were not severe or frequent enough to warrant surgery, and surgery was recommended in the remaining 5 patients. Chiari malformation Type I was also diagnosed in 43 asymptomatic patients who had imaging studies performed for various reasons. No new neurological deficits were noted in any patient for the duration of follow-up.
The majority of patients with CM-I who are followed up without surgery do not progress clinically or radiologically. Longer follow-up of this cohort will be required to determine if symptoms or new neurological findings develop over the course of many years.