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Miguel A. Melgar and Martin E. Weinand

Medically refractory positional cerebral ischemia and concomitant orthostatic hypotension associated with chronic common carotid artery (CCA) occlusion are rare. The authors detail their experience with three cases treated exclusively by an extracranial bypass in which the thyrocervical trunk was used as the donor vessel. Postoperatively grafts were patent and symptoms resolved in all three patients, although orthostatic hypotension remained. Postural cerebral ischemia due to CCA occlusion can be treated by extracranial bypass surgery. The thyrocervical trunk is a suitable donor for reconstruction of the external carotid artery in these cases.

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Miguel A. Melgar, Deshdeepak Sahni and Martin Weinand

✓ Medically refractory positional cerebral ischemia (PCI) and concomitant orthostatic hypotension associated with chronic common carotid artery (CCA) occlusion are rare. In this technical report, the authors describe an extracranial bypass in which the thyrocervical trunk was used as a donor vessel to treat three cases of CCA occlusion with PCI. Postoperatively, although orthostatic hypotension remained, ischemia-related symptoms resolved in all three patients and long-term graft patency was demonstrated. It is possible to treat cerebral ischemia due to CCA occlusion with extracranial bypass surgery. In these patients, the thyrocervical trunk proved to be a suitable donor vessel for the reconstitution of blood flow within the external carotid artery.

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Intradiploic arachnoid cysts

Report of two cases

Martin E. Weinand, Setti S. Rengachary, Douglas H. McGregor and Itaru Watanabe

✓ Two patients are presented in whom cranial arachnoid cysts developed as diverticuli of the arachnoid membrane through small defects in the dura mater, eroded through the inner table, expanded within the diploe, and eroded the outer table of the skull. Based on observations at the time of surgery and the histological examination of these lesions, it is proposed that they are congenital in origin. Previously reported cases of “traumatic arachnoid cyst without fracture,” “intradiploic cerebrospinal fluid fistula,” and “middle fossa pitholes” appear to represent the same pathological process as the lesions reported in this paper. It is proposed that “intradiploic arachnoid cyst” is the most appropriate term by which these lesions should be described.

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Martin E. Weinand, Allen R. Wyler, E. T. Richey, Barbara B. Phillips and Grant W. Somes

✓ Long-term electrocorticographic (ECoG) monitoring data from subdural strip electrodes are analyzed to determine factors associated with seizure-free outcome from anterior temporal lobectomy. A total of 89 consecutive patients with complex partial seizures, in whom long-term ictal video/scalp electroencephalographic monitoring was insufficient to localize their epileptogenic focus, were subsequently evaluated with long-term ictal ECoG monitoring using subdural strip electrodes. Each patient underwent anterior temporal lobectomy based on the ictal ECoG data and has been followed for at least 1 year. The following parameters were found to be statistically significant in predicting a seizure-free outcome: unilateral onset, electrical onset pattern beginning as fast spike trains, absence of frontal lobe background desynchronization at onset, and an interhemispheric propagation time of greater than 8 seconds. Electrocorticographic criteria that were not associated with seizure outcome included: right- versus left-sided onset, time from electrical to clinical ictal onset, focality of onset (number of strip electrode contacts involved), and stereotypical ECoG onset. When present, the interictal focus was concordant with the ictal focus in most patients (96%), but was falsely lateralizing in 4% of cases. It is suggested that these data should improve patient selection for temporal lobectomy when subdural strip monitoring is used during preoperative evaluation.

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Robert Levy, Sean Ruland, Martin Weinand, David Lowry, Rima Dafer and Roy Bakay

Object

In this prospective multicenter study the authors hypothesized that investigational epidural cortical stimulation (CS) delivered concurrently with rehabilitation therapy may enhance motor recovery following stroke.

Methods

Patients who had suffered their index stroke ≥ 4 months previously were randomized into 6 weeks of rehabilitation therapy with or without CS. Cortical stimulation, targeted by functional imaging, was delivered at ~ 50% of motor movement threshold. Primary outcome measures were Upper Extremity Fugl-Meyer (UEFM [a measure of neurological and motor function]) and Arm Motor Ability Test (AMAT [a measure of activities of daily living]) scores. The primary study end point was 4 weeks following rehabilitation therapy.

Results

A total of 24 patients, 12 per group, completed the treatment protocol. The mean interval since the patients' index stroke was 33 months (range 4–100 months). There were no deaths or cases of neurological deterioration; 1 acute postoperative seizure occurred unrelated to the device or treatment. Patients who underwent CS experienced improved hand/arm function more than control patients. The UEFM score improved 5.5 ± 4.4 points in patients in the CS group compared with 1.9 ± 4.4 points for controls (p = 0.03). A 3.5-point UEFM improvement is considered clinically meaningful. The AMAT scores for the CS group improved by 0.4 ± 0.6 points, whereas the scores in the control group improved by 0.2 ± 0.4 points (p = 0.2). A 0.21-point improvement in AMAT score is considered clinically meaningful. In the CS group, 67% of patients had clinically meaningful improvement in UEFM scores, compared with 25% of the control group (p = 0.05). Of patients in the CS group 50% had clinically meaningful improvement in UEFM as well as AMAT scores, compared with only 8% of those in the control group (p = 0.03).

Conclusions

These results suggest that subthreshold epidural CS is safe and effective during rehabilitation for recovery of arm and hand function following hemiparetic stroke. Further research in a larger cohort is needed to validate the therapeutic effect.

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Martin E. Weinand, L. Philip Carter, Waleed F. El-Saadany, Panayiotis J. Sioutos, David M. Labiner and Kalarickal J. Oommen

Long-term surface cerebral blood flow (CBF) monitoring was performed to test the hypothesis that temporal lobe epileptogenicity is a function of epileptic cortical perfusion. Forty-three bitemporal 2-hour periictal CBF studies were performed in 13 patients. Homotopic regions of temporal cortex maintained interictal epileptic cortical hypoperfusion and nonepileptic normal cortical CBF. At 10 minutes preictus, a statistically significant, sustained increase in CBF was detected on the epileptic temporal lobe. Two minutes preictus, there was approximation of CBF in the epileptic and nonepileptic temporal lobes. Thereafter, electrocorticographic (ECoG) and clinical seizure onset occurred. The linear relationship between CBF in the two hemispheres (epileptic and nonepileptic) was the inverse of normal (y = -0.347x + 62.767, r = 0.470, df = 95, p < 0.05). The data indicated a direct linear correlation between epileptic cortical CBF and seizure interval (frequency-1), a clinical measure of epileptogenicity (r = 0.610, df = 49, p < 0.05). Epileptogenicity was also found to be a logarithmic function of the difference between nonepileptic and epileptic cortical perfusion (r = 0.564, df = 58, t = 5.20, p < 0.05). The results showed that progressive hypoperfusion of the epileptic focus correlated with a decreased seizure interval (increased epileptogenicity). Increased perfusion of the epileptic focus correlated with an increased seizure interval (decreased epileptogenicity). The fact that CBF alterations precede ECoG seizure activity suggests that vasomotor changes may produce electrical and clinical seizure onset.

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Martin E. Weinand, L. Philip Carter, Waleed F. El-Saadany, Panayiotis J. Sioutos, David M. Labiner and Kalarickal J. Oommen

✓ Long-term surface cerebral blood flow (CBF) monitoring was performed to test the hypothesis that temporal lobe epileptogenicity is a function of epileptic cortical perfusion. Forty-three bitemporal 2-hour periictal CBF studies were performed in 13 patients. Homotopic regions of temporal cortex maintained interictal epileptic cortical hypoperfusion and nonepileptic normal cortical CBF. At 10 minutes preictus, a statistically significant, sustained increase in CBF was detected on the epileptic temporal lobe. Two minutes preictus, there was approximation of CBF in the epileptic and nonepileptic temporal lobes. Thereafter, electrocorticographic (ECoG) and clinical seizure onset occurred. The linear relationship between CBF in the two hemispheres (epileptic and nonepileptic) was the inverse of normal (y = −0.347x + 62.767, r = 0.470, df = 95, p < 0.05). The data indicated a direct linear correlation between epileptic cortical CBF and seizure interval (frequency−1), a clinical measure of epileptogenicity (r = 0.610, df = 49, p < 0.05). Epileptogenicity was also found to be a logarithmic function of the difference between nonepileptic and epileptic cortical perfusion (r = 0.564, df = 58, t = 5.20, p < 0.05). The results showed that progressive hypoperfusion of the epileptic focus correlated with a decreased seizure interval (increased epileptogenicity). Increased perfusion of the epileptic focus correlated with an increased seizure interval (decreased epileptogenicity). The fact that CBF alterations precede ECoG seizure activity suggests that vasomotor changes may produce electrical and clinical seizure onset.