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Marvin Bergsneider, John G. Frazee and Antonio A. DeSalles

✓ The authors report the case of a 7-mm saccular aneurysm, located within the third ventricle and arising from the distal portion of a thalamostriate artery. The patient presented with an intraventricular hemorrhage and was treated via a frontotemporal craniotomy with translamina-terminalis approach for resection of the aneurysm. The etiology of the aneurysm was presumed to be idiopathic. Previously only one other third ventricular aneurysm has been reported. An intraventricular aneurysm arising from a perforating artery should therefore be considered as a rare cause of an intraventricular hemorrhage. Potential surgical approaches to third ventricular aneurysms are discussed.

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John G. Frazee, Steven L. Giannotta and W. Eugene Stern

✓ A primate model of chronic cerebral vasoconstriction is presented which closely approximates the human experience following subarachnoid hemorrhage. Treatment of the vasoconstriction with intravenous nitroglycerin produces a modest, but statistically significant, increase in the size of the most constricted vessels (11%, p < 0.02) when compared with a control infusion of normal saline. The significance of these experiments is discussed.

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John G. Frazee, Leslie D. Cahan and James Winter

✓ The treatment of 13 patients with bacterial intracranial aneurysms is reported. The incidence of bacterial intracranial aneurysms was 4% of all patients admitted with intracranial aneurysms and 3% of all patients admitted with bacterial endocarditis. Each patient had neurological signs or symptoms suggestive of intracranial disease prior to the diagnosis of an aneurysm. Alpha Streptococcus was the most common infecting organism. All patients were treated with specific, high-dose antibiotics, and five patients underwent surgery as well. There were no surgical deaths. Six of eight nonsurgically treated patients died. A review of the literature confirms a high mortality for patients treated with only antibiotics, and a low mortality for elective surgery. The authors conclude that 1) patients with bacterial endocarditis, who develop sudden severe headache, focal neurological signs or symptoms, or seizures, should undergo serial cerebral angiography every 7 to 10 days throughout their hospitalization; 2) if an aneurysm is identified it should be excised whenever possible; and 3) patients with proximal or multiple aneurysms should be considered for surgery.

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John G. Frazee, John A. Bevan, Rosemary D. Bevan and K. Roy Jones

✓ The influence of diltiazem on chronic cerebral vasospasm was studied following subarachnoid hemorrhage (SAH) in a primate model. The model mimics the human experience including the production of neurological deficits. Six monkeys were pretreated with diltiazem (25 mg/kg twice daily) for 2 days prior to surgical production of an SAH and for 5 days after the hemorrhage. This group was compared with six untreated monkeys that also sustained an SAH. The mean diameter of cerebral arteries measured at six angiographic sites was 60.6% of the pre-SAH diameter for the untreated group and 99.7% for the diltiazem-treated group. These values are significantly different (p < 0.0005). There was no neurological deficit in the pretreated animals. The mean diameter of the “most constricted vessel” in each experiment was 22% of the prehemorrhage diameter for the untreated and 84% for the treated group (p < 0.0005). Arterial pressure was unaffected by the dosage regimen. These experiments with this primate model of chronic cerebral vasospasm demonstrate that vascular narrowing and neurological deficit can be markedly attenuated by diltiazem pretreatment.

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Aaron R. Cutler, Sean W. Kaloostian, Akira Ishiyama and John G. Frazee

Object

Vestibular nerve sectioning is an accepted surgical treatment option for patients with medically refractory Ménière disease. In this paper the authors introduce and evaluate a 2-handed endoscopic-directed technique for vestibular nerve section.

Methods

Eleven patients underwent a retrosigmoid craniectomy for endoscopic-directed vestibular nerve sectioning as treatment for intractable vertigo associated with Ménière disease. In all patients, identification and dissection of the cranial nerve VII/VIII complex was performed entirely under endoscopic guidance. The authors used the specially designed Frazee II neuroendoscope, consisting of a traditional endoscope lens with a microsuction attachment.

Results

Vestibular nerve sectioning was completed in all 11 patients. Postoperative improvement in vertiginous episodes was achieved in 10 patients (91%). Auditory function was noted to be worse postoperatively in only 1 patient (9%). The same patient also developed a House-Brackmann Grade III facial nerve palsy, which improved gradually over time. There were no further complications, including no delayed CSF leaks.

Conclusions

The endoscopic-directed approach represents a safe and effective method for performing vestibular nerve sectioning. Until now, the endoscope has been used primarily as an adjunct to the operating microscope in surgery at the cerebellopontine angle. In addition, previous endoscopic techniques typically require a third hand to manipulate the endoscope. With the 2-handed endoscopic-directed technique, however, the endoscope is used as the primary means of visualization, and the unique design of this endoscope allows for a bimanual procedure without the requirement of a cosurgeon. Advantages of using this technique compared with the microscope include superior brightness at close distances, greater depth of field, increased maneuverability within small regions, and an improved ability to visualize objects not in a direct line of sight. Among other things, this allows for minimally invasive openings, decreased cerebellar retraction, and better identification of nerve cleavage planes and vascular anatomy.

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Marvin Bergsneider, Langston T. Holly, Jae Hong Lee, Wesley A. King and John G. Frazee

In this report the authors review their 3-year experience with the endoscopic management of patients with hydrocephalus who harbored cysticercal cysts within the third and lateral ventricles. The management plan was to utilize an endoscopic approach to remove the cysts and to incorporate techniques useful in treating obstructive hydrocephalus. The ultimate goals were to avoid having to place a complication-prone cerebrospinal fluid shunt and to eliminate the risk of complications related to cyst degeneration.

A retrospective analysis of 10 endoscopically managed patients with hydrocephalus and cysticercal cysts within the third or lateral ventricles was performed. A general description of the instrumentation and the technique used for removal of the intraventricular cysts is given. At presention, neuroimaging revealed findings suggestive of obstructive hydrocephalus in eight patients.

Seven of the 10 patients treated endoscopically were spared the necessity of shunt placement. Three successful third ventriculostomies and one therapeutic septum pellucidotomy were performed. Despite frequent rupture of the cyst walls during removal of the cyst, there were no cases of ventriculitis. The endoscopic approach successfully allowed removal of a cyst situated in the roof of the anterior third ventricle. One patient suffered from recurrent shunt obstructions secondary to a shunt-induced migration of cysts from the posterior fossa to the lateral ventricles.

The endoscopic removal of third and lateral ventricle cysticercal cysts, combined with a third ventriculostomy or septum pellucidotomy in selected cases, is an effective treatment in patients with hydrocephalus and should be considered the primary treatment for this condition.

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Marvin Bergsneider, Langston T. Holly, Jae Hong Lee, Wesley A. King and John G. Frazee

Object. In this report the authors review their 3-year experience with the endoscopic management of patients with hydrocephalus who harbored cysticercal cysts within the third and lateral ventricles. The management plan was to utilize an endoscopic approach to remove the cysts and to incorporate techniques useful in treating obstructive hydrocephalus. The ultimate goals were to avoid having to place a complication-prone cerebrospinal fluid shunt and to eliminate the risk of complications related to cyst degeneration.

Methods. A retrospective analysis of 10 patients with hydrocephalus and cysticercal cysts within the third or lateral ventricles who were endoscopically managed was performed. A general description of the instrumentation and technique used for removal of the intraventricular cysts is given. At presentation, neuroimaging revealed findings suggestive of obstructive hydrocephalus in eight patients.

Seven of the 10 patients treated endoscopically were spared the necessity of shunt placement. Three successful third ventriculostomies and one therapeutic septum pellucidotomy were performed. Despite frequent rupture of the cyst walls during removal of the cysts, there were no cases of ventriculitis. The endoscopic approach allowed successful removal of a cyst situated in the roof of the anterior third ventricle. One patient suffered from recurrent shunt obstructions secondary to a shunt-induced migration of cysts from the posterior fossa to the lateral ventricles.

Conclusions. The endoscopic removal of third and lateral ventricle cysticercal cysts, combined with a third ventriculostomy or septum pellucidotomy in selected cases, is an effective treatment in patients with hydrocephalus and should be considered the primary treatment for this condition.

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Joon K. Song, Fernando Viñuela, Y. Pierre Gobin, Gary R. Duckwiler, Yuichi Murayama, Inam Kureshi, John G. Frazee and Neil A. Martin

Object. The authors assessed clinical outcomes of patients with treated spinal dural arteriovenous fistulas (DAVFs) and investigated prognostic factors.

Methods. Thirty consecutive patients with spinal DAVFs were treated at the authors' institution during the past 15 years: seven underwent surgery; seven underwent surgery after failed embolization; and 16 underwent embolization alone. The outcomes of gait and micturition disability were analyzed. Follow up averaged 3.4 years (range 1 month–11.8 years). Age, duration of symptoms, pre- and postintervention magnetic resonance (MR) imaging findings, and preintervention disability were correlated with outcome.

Seventeen patients (57%) experienced improved gait, 12 (40%) were unchanged, and one (3%) was worse. In 11 patients (37%) micturition function was improved, in 15 (50%) it was unchanged, and in four (13%) it was worse. Gait disability, as measured by the Aminoff—Logue Scale, was significantly improved after treatment, from 3.4 ± 1.4 (average ± standard deviation) to 2.7 ± 1.5 (p = 0.007). Mean micturition disability scores decreased, but not significantly, from 1.9 ± 1 to 1.6 ± 1.1 (p = 0.20). Preintervention gait disability was not associated with improvement except for patients with Aminoff—Logue Scale Grade 4 disability (eight of nine improved; p = 0.024). For patients treated within 13 months of symptom onset, mean micturition disability decreased (p = 0.035). No association was found between clinical improvement and age, a symptom duration less than 30 months, or pre- and postintervention MR imaging—documented spinal cord edema.

Conclusions. Spinal DAVF treatment significantly improved patients' mean gait disability score by almost one grade at last follow up. The mean micturition disability score was not significantly improved, unless treatment was performed within 13 months of symptom onset. Longer and more uniform follow-up study is needed to determine if improved and stabilized clinical outcomes are sustained.