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Editorial

Hypertonic saline

Alan Hoffer and Warren R. Selman

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Martin M. Mortazavi, R. Shane Tubbs, Daniel Harmon and W. Jerry Oakes

Chronic emesis may result from a variety of causes. To the authors' knowledge, compression of the area postrema by regional vessels resulting in chronic emesis has not been reported.

The authors report on a child who presented with chronic medically intractable emesis and significant weight loss requiring jejunostomy feeding. Surgical exploration of the posterior cranial fossa found unilateral compression of the area postrema by the posterior inferior cerebellar artery. Microvascular decompression resulted in postoperative and long-term resolution of the patient's emesis.

Although apparently very rare, irritation of the area postrema from the posterior inferior cerebellar artery with resultant medically intractable chronic emesis may occur. Therefore, the clinician should be aware of this potential etiology when dealing with such patients.

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R. Shane Tubbs, Martin M. Mortazavi, Andrew J. Denardo and Aaron A. Cohen-Gadol

The artery of Desproges-Gotteron is rarely mentioned in the literature and is unfamiliar to most neurosurgeons. The authors report a unique case of an arteriovenous malformation (AVM) of the conus in an adult woman, which received blood supply from an artery of Desproges-Gotteron. The patient presented with intermittent pain radiating down the right posterior thigh and foot and transient bladder incontinence. On examination, there was weakness of the right lower limb with hypalgesia of the plantar aspect of the right foot. Magnetic resonance imaging revealed a mass near the anterior aspect of the conus medullaris and angiography confirmed a spinal AVM at the L-1 level and a shunt located at the inferior L-3 level. The patient underwent transarterial embolization, and at 2-year follow-up, repeat angiography demonstrated no evidence of residual or recurrent spinal AVM, intermittent and tolerable pain without treatment interventions, and a normal neurological examination. The artery of Desproges-Gotteron appears to be a rare arterial variation. Moreover, the authors believe this to be the first case of a conal AVM supplied by such an artery. The anatomy and implications of such an arterial variant are discussed.

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Martin Mortazavi, Aman Deep, R. Shane Tubbs and Wink S. Fisher III

Manuscript submitted May 23, 2011. Accepted September 25, 2011. Kenneth Grant Jamieson is celebrated as one of Australia's top neurosurgeons. His most notable contributions to neurosurgery included novel treatments of aneurysms and pineal tumors and studies of head injury. Jamieson was also an innovator for the development of new neurosurgical instruments and renowned for his teaching abilities, prolificacy, and mentorship. This preeminent neurosurgeon's life was cut short at the age of 51. Our current understanding and knowledge of treatments of various neurosurgical diseases is based on pioneers such as Kenneth Grant Jamieson.

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R. Shane Tubbs, Martin M. Mortazavi, Sanjay Krishnamurthy, Ketan Verma, Christoph J. Griessenauer and Aaron A. Cohen-Gadol

Object

During intracranial approaches to the skull base, vascular relationships are important. One relationship that has received scant attention in the literature is that between the superior petrosal sinus (SPS) and the opening of the Meckel cave (that is, the porus trigeminus).

Methods

Cadaver dissections were performed in 25 latex-injected adult cadaveric heads (50 sides). Specifically, the relationship between the SPS and the opening of the Meckel cave was observed. The goal was to enhance knowledge of the relationship between the SPS and the opening of the Meckel cave.

Results

Of the 50 sides, 68%, 18%, and 16% of SPSs traveled superior to, inferior to, and around the opening to the Meckel cave, respectively. In the latter cases, a venous ring was formed around the proximal trigeminal nerve. No sinus entered the Meckel cave. In general, the porus trigeminus was narrowed on sides found to have an SPS that encircled this region. Sinuses that traveled only inferior to the porus were in general smaller than sinuses that traveled superior or encircled this opening. No statistically significant differences were noted between the various sinus relationships and sex, age, or side of the head.

Conclusions

Knowledge of the relationship between the SPS and the opening of the Meckel cave may be useful to the skull base surgeon. Based on this study, some individuals may retain the early embryonic position of their SPS in relation to the trigeminal nerve.

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Martin M. Mortazavi, Andrew K. Romeo, Aman Deep, Christoph J. Griessenauer, Mohammadali M. Shoja, R. Shane Tubbs and Winfield Fisher

Object

Currently, mannitol is the recommended first choice for a hyperosmolar agent for use in patients with elevated intracranial pressure (ICP). Some authors have argued that hypertonic saline (HTS) might be a more effective agent; however, there is no consensus as to appropriate indications for use, the best concentration, and the best method of delivery. To answer these questions better, the authors performed a review of the literature regarding the use of HTS for ICP reduction.

Methods

A PubMed search was performed to locate all papers pertaining to HTS use. This search was then narrowed to locate only those clinical studies relating to the use of HTS for ICP reduction.

Results

A total of 36 articles were selected for review. Ten were prospective randomized controlled trials (RCTs), 1 was prospective and nonrandomized, 15 were prospective observational trials, and 10 were retrospective trials. The authors did not distinguish between retrospective observational studies and retrospective comparison trials. Prospective studies were considered observational if the effects of a treatment were evaluated over time but not compared with another treatment.

Conclusions

The available data are limited by low patient numbers, limited RCTs, and inconsistent methods between studies. However, a greater part of the data suggest that HTS given as either a bolus or continuous infusion can be more effective than mannitol in reducing episodes of elevated ICP. A meta-analysis of 8 prospective RCTs showed a higher rate of treatment failure or insufficiency with mannitol or normal saline versus HTS.

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M. Asif Taqi, Sajid S. Suriya, Ajeet Sodhi, Syed A. Quadri, Mudassir Farooqui, Atif Zafar and Martin M. Mortazavi

OBJECTIVE

Several retrospective studies have supported the use of conscious sedation (CS) over general anesthesia (GA) as the preferred methods of sedation for stroke thrombectomy, but a recent randomized controlled trial showed no difference in outcomes after CS or GA. The purpose of the Ideal Sedation for Stroke Thrombectomy (ISST) study was to evaluate the difference in time and outcomes in the reperfusion of anterior circulation in ischemic stroke using GA and monitored anesthesia care (MAC).

METHODS

The ISST study was a prospective, open-label registry. A total of 40 patients who underwent mechanical thrombectomy for anterior circulation ischemic stroke were enrolled. Informed consent was obtained from each patient before enrollment. The primary endpoint included the interval between the patient’s arrival to the interventional radiology room and reperfusion time. Secondary endpoints were evaluated to estimate the effects on the outcome of patients between the 2 sedation methods.

RESULTS

Of the 40 patients, 32 received thrombectomy under MAC and 8 patients under GA. The male-to-female ratio was 18:14 in the MAC group and 4:4 in the GA group. The mean time from interventional radiology room arrival to reperfusion in the GA group was 2 times higher than that in the MAC group. Complete reperfusion (TICI grade 3) was achieved in more than 50% of patients in both groups. The mean modified Rankin Scale score at 3 months was < 2 in the MAC group and > 3 in the GA group (p = 0.021).

CONCLUSIONS

The findings from the pilot study showed a significantly shorter time interval between IR arrival and reperfusion and better outcomes in patients undergoing reperfusion for ischemic stroke in the anterior circulation using MAC compared with GA.

Clinical trial registration no.: NCT03036631 (clinicaltrials.gov)

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Martin M. Mortazavi, R. Shane Tubbs, Maja Andrea Brockerhoff, Marios Loukas and W. Jerry Oakes

Few are familiar with the neurological contributions of the German pathologist Theodor Langhans. Even fewer are aware of his significant and early contributions to the study of what is now known as the Chiari I malformation. In at least 4 cases, Langhans described the association between tonsillar ectopia and syringomyelia. Moreover, this early pioneer speculated that there was a cause and effect with hindbrain herniation resulting in improper flow at the craniocervical junction and consequent development of syringomyelia. These cases were reported prior to Hans Chiari's descriptions, and Langhans' theory of impeded foramen magnum flow as a cause of syringomyelia was novel and preceded the current understanding of this mechanism by almost a century. The authors discuss the life of Langhans and translate excerpts from his 1881 work regarding tonsillar ectopia and syringomyelia.

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Joshua J. Chern, Amber J. Gordon, Martin M. Mortazavi, R. Shane Tubbs and W. Jerry Oakes

Object

In 1998 the authors identified 5 patients with syringomyelia and no evidence of Chiari malformation Type I (CM-I). Magnetic resonance imaging of the entire neuraxis ruled out other causes of a syrinx. Ultimately, abnormal CSF flow at the foramen magnum was the suspected cause. The label “Chiari 0” was used to categorize these unique cases with no tonsillar ectopia. All of the patients underwent posterior fossa decompression and duraplasty identical to the technique used to treat patients with CM-I. Significant syrinx and symptom resolution occurred in these patients. Herein, the authors report on a follow-up study of patients with CM-0 who were derived from over 400 operative cases of pediatric CM-I decompression.

Methods

The authors present their 12-year experience with this group of patients.

Results

Fifteen patients (3.7%) were identified. At surgery, many were found to have physical barriers to CSF flow near the foramen magnum. In most of them, the syringomyelia was greatly diminished postoperatively.

Conclusions

The authors stress that this subgroup represents a very small cohort among patients with Chiari malformations. They emphasize that careful patient selection is critical when diagnosing CM-0. Without an obvious CM-I, other etiologies of a spinal syrinx must be conclusively ruled out. Only then can one reasonably expect to ameliorate the clinical course of these patients via posterior fossa decompression.

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Christoph J. Griessenauer, R. Shane Tubbs, Mohammadali M. Shoja, Joel Raborn, Christopher J. Boes, Martin M. Mortazavi and Giuseppe Lanzino

Alfred W. Adson was a pioneer in the field of neurosurgery. He described operations for a variety of neurosurgical diseases and developed surgical instruments. Under his leadership the Section of Neurological Surgery at the Mayo Clinic was established and he functioned as its first chair. Adson's contributions to the understanding of spinal and spinal cord tumors are less well known. This article reviews related medical records and publications and sets his contributions in the context of the work of other important pioneers in spinal tumor surgery at the time.