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Joseph M. Piepmeier

✓ The records of 60 patients with low-grade astrocytic tumors of the cerebral hemispheres treated between 1975 and 1985 were examined to evaluate the results of current treatment methods. This analysis revealed that the patient's age and tumor enhancement on computerized tomography (CT) with intravenous administration of contrast material were the only factors that influenced survival time. Compared to prior studies, the patients in this report more frequently had normal preoperative neurological examinations and total resection of their lesions. These differences may have resulted from the use of CT scans over the past decade. Earlier diagnosis and improvement definition of the tumor location and extent are two reasons why the use of CT scans may have affected outcome statistics. A re-examination of treatment methods and the timing of those treatments is needed to define the optimal management of these lesions.

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Low-Grade Gliomas

Neurosurgical Focus, February 2002

Joseph M. Piepmeier

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Joseph M. Piepmeier

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Joseph M. Piepmeier and N. Ross Jenkins

✓ Sixty-nine patients with traumatic spinal cord injuries were evaluated for changes in their functional neurological status at discharge from the hospital, and at 1 year, 3 years, and 5+ years following injury. The neurological examinations were used to classify patients' spinal cord injury according to the Frankel scale. This analysis revealed that the majority of improvement in neurological function occurred within the 1st year following injury; however, changes in the patients' status continued for many years. Follow-up examinations at an average of 3 years postinjury revealed that 23.3% of the patients continued to improve, whereas 7.1% had deteriorated compared to their status at 1 year. An examination at an average of 5+ years demonstrated further improvement in 12.5%, with 5.0% showing deterioration compared to the examinations at 3 years. These results demonstrate that, in patients with spinal trauma, significant changes in neurological function continue for many years.

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Hahnah Kasowski and Joseph M. Piepmeier

Tumors that arise within the ventricles present a unique surgical challenge. Because of their deep location, relatively large size, and their association with hydrocephalus, surgical planning requires a careful assessment of the optimal method to access the lesion and to provide adequate exposure for tumor resection. The transcallosal approach to the lateral ventricles often is the best procedure by which to achieve these goals.

Partial sectioning of the corpus callosum does not cause significant neurological deficits; however, if the surgery induces additional brain injury, the neurological deficits can be more severe in the presence of a callosotomy. Knowledge of the techniques of transcallosal surgery and careful preoperative planning can reduce the risk of permanent neurological impairment; these range from protection of the cortical veins that drain into the superior sagittal sinus to brain relaxation and ventricular drainage, as well as proper identification of anatomical landmarks within the ventricle. The transcallosal approach can offer a relatively easy access to the lateral and third ventricles, and with proper planning it can reduce the morbidity associated with resection of lesions within these compartments.

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Lee L. Thibodeau, Aurelio Ariza and Joseph M. Piepmeier

✓ This report describes a case of primary leptomeningeal sarcomatosis in a 50-year-old man who presented with progressive deficits involving multiple cranial nerves and spinal roots. Despite the clinical evidence supporting a diffuse process involving the leptomeninges, radiological, serological, and cerebrospinal fluid examinations failed to reveal the cause of the disorder. Consequently, surgical exploration and biopsy were required to obtain a pathological diagnosis. This case report illustrates the difficulty in diagnosing this disease and supports the use of open biopsy in patients with chronic meningeal disease when the diagnosis cannot be established by less invasive methods.

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Thierry J. Hufnagel, Carlos Artiles, Joseph Piepmeier, Leon Kier and Jung H. Kim

✓ Desmoplastic fibroma is a distinctive and rare neoplasm of bone. Only one previous example has been reported in the calvaria. The diagnostic and surgical aspects of a case of desmoplastic fibroma of the skull that radiographically simulated eosinophilic granuloma are reported.

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Thomas A. Duff, Ernest Borden, Janet Bay, Joseph Piepmeier and Karen Sielaff

✓ Twelve patients were admitted to a Phase II study on the treatment of recurrent glioblastoma multiforme with interferon-β (IFN-β). All patients had previously undergone craniotomy and received a standard course of radiation therapy. Recurrence was inferred from enlargement of the lesion on computerized tomography (CT) scanning and in each case was confirmed by CT-guided stereotaxic biopsy. Treatment consisted of combined intravenous (10 × 106 IU/day) and intratumoral (1 × 106 IU every other day) administration of IFN-β over three 10-day cycles. This regimen was well tolerated, with toxicity requiring temporary dose modifications in five patients. As judged from data from historical cases, however, the patients admitted to this study demonstrated no clear improvement in mean survival time. The findings of this study also emphasize the importance of distinguishing between radiation necrosis and tumor recurrence.

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Alexandre C. Carpentier, R. Todd Constable, Michael J. Schlosser, Alain de Lotbinière, Joseph M. Piepmeier, Dennis D. Spencer and Issam A. Awad

Object. Functional magnetic resonance (fMR) imaging of the motor cortex is a potentially powerful tool in the preoperative planning of surgical procedures in and around the rolandic region. Little is known about the patterns of fMR imaging activation associated with various pathological lesions in that region or their relation to motor skills before surgical intervention.

Methods. Twenty-two control volunteers and 44 patients whose pathologies included arteriovenous malformations (AVMs; 16 patients), congenital cortical abnormalities (11 patients), and tumors (17 patients) were studied using fMR imaging and a hand motor task paradigm. Activation maps were constructed for each participant, and changes in position or amplitude of the motor activation on the lesion side were compared with the activation pattern obtained in the contralateral hemisphere. A classification scheme of plasticity (Grades 1–6) based on interhemispheric pixel asymmetry and displacement of activation was used to compare maps between patients, and relative to hand motor dexterity and/or weakness.

There was 89.4% interobserver agreement on classification of patterns of fMR imaging activation. Displacement of activation by mass effect was more likely with tumors. Cortical malformations offer a much higher functional reorganization than AVMs or tumors. High-grade plasticity is recruited to compensate for severe motor impairment.

Conclusions. Pattern modification of fMR imaging activation can be systematized in a classification of motor cortex plasticity. This classification has shown good correlation among grading, brain lesions, and motor skills. This proposal of a classification scheme, in addition to facilitating data collection and processing from different institutions, is well suited for comparing risks associated with surgical intervention and patterns of functional recovery in relation to preoperative fMR imaging categorization. Such studies are underway at the authors' institution.

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Eugene S. Flamm, Wise Young, William F. Collins, Joseph Piepmeier, Guy L. Clifton and Boguslav Fischer

✓ Results of a Phase I trial of the opiate antagonist naloxone for treatment of patients with acute spinal cord injury are reported. Naloxone was administered in doses ranging from 5 to 200 mg/sq m (0.14 to 5.4 mg/kg) for up to 48 hours. The patients ranged in age from 16 to 79 years (mean 37 years). Twenty patients received naloxone as a loading dose of 5 to 50 mg/sq m (0.14 to 1.43 mg/kg), followed by a maintenance dose of 20% of the loading dose given as a continuous infusion hourly for 47 hours (Group 1). Nine patients received a loading dose of 100 to 200 mg/sq m (2.7 to 5.4 mg/kg) and a maintenance dose of 75% of the initial dose hourly for 23 hours (Group 2). These higher doses (2.7 to 5.4 mg/kg) have been found to be effective in experimental spinal cord injury. Neurological examinations were performed and somatosensory evoked potentials (SEP's) were obtained as soon after admission as possible and again 1, 2, 3, and 7 days, 3 weeks, and 6 weeks to 6 months after admission.

The 20 Group 1 patients who received 1.43 mg/kg or less of naloxone showed no improvement in neurological status or SEP's. All but three (15%) of these patients had a complete neurological deficit at the time of admission. Treatment was begun an average of 12.9 hours after injury. Among the nine Group 2 patients treated with 2.7 mg/kg or more, there were five patients (56%) with incomplete deficits. This group received naloxone an average of 6.6 hours after admission. Two of the five Group 2 patients with incomplete lesions showed improvement in their neurological condition and/or SEP's within 36 hours of receiving the drug. One of the four Group 2 patients with a complete lesion at the time of admission was able to localize pressure sensation in his legs 36 hours after completion of the drug infusion. Four Group 2 patients (two with complete and two with incomplete lesions) have shown improvement in their SEP's, suggesting recovery of SEP's in a dose-related fashion. Four patients experienced increased pain after administration of the loading dose and during the maintenance infusion; in only one patient was this severe enough to require discontinuation of the drug. Of the 29 patients treated with naloxone, four died within 6 weeks of admission, for a mortality rate of 13.8%.

This study demonstrates that, in spinal cord-injured patients, naloxone given as an intravenous loading dose of 200 mg/sq m, followed by a continuous infusion of up to 150 mg/sq m/hr for 23 hours, has minimal side effects. The observed improvement in the clinical examination and SEP's at the higher doses, while not statistically verified in this Phase I trial, is encouraging.