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Michael M. Haglund, George A. Ojemann and Gary G. Blasdel

✓ In order to better understand the degree of cortical activation that occurs during bipolar surface stimulation, the authors stimulated monkey visual cortex while monitoring the degree of activation with optical imaging. Optical imaging of intrinsic signals in monkey visual cortex during visual stimulation resulted in functional maps of ocular dominance and orientation selectivity. After functional maps of ocular dominance and orientation preference were obtained, bipolar surface stimulation was applied to activate just the cortical areas around the bipolar electrodes. Graded responses to changes in the stimulation intensity and duration were found. These findings demonstrate the reliability of bipolar cortical surface stimulation in localizing functional regions of cortex. The area of activation, at least in the region around the bipolar stimulating electrodes, did not appear to activate nearby ocular dominance columns or orientation patches. Intraoperative bipolar surface stimulation continues to be a consistently reliable technique for localizing rolandic cortex and essential language sites.

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Kim J. Burchiel, Hadley Clarke, Michael Haglund and John D. Loeser

✓ Forty patients were followed for an average period of 8½ years after 44 consecutive suboccipital craniotomies for trigeminal neuralgia. Among these patients, 36 had microvascular decompression (MVD) of the nerve, four had repeat trigeminal rhizotomy after MVD was not successful in controlling their pain, and four had primary trigeminal rhizotomies. Of the 36 patients undergoing MVD, 17 (47%) experienced recurrent postoperative neuralgic pain: in 11 (31%) pain recurrence was major, and in six (17%) it was minor. Among the eight patients undergoing rhizotomy, four (50%) had major pain recurrences and one (13%) had a minor recurrence, for a 63% total recurrence rate. There was a strong statistical relationship between an operative finding of arterial cross-compression of the nerve and long-term complete pain relief. Patients with other compressive pathology (related to veins or bone structures) did not on the average fare as well. Despite this, there appeared to be no point in time in the postoperative interval when the patient could be considered “cured.” Major recurrences averaged 3.5% annually, and minor recurrences averaged 1.5% annually. The implications of these findings for the treatment of trigeminal neuralgia and the current understanding of the mechanism of MVD for this disorder are discussed.

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Sandra Serafini, Sridharan Gururangan, Allan Friedman and Michael Haglund

✓A bilingual pediatric patient who underwent tumor resection was mapped extraoperatively using cortical stimulation to preserve English and Hebrew languages. The authors mapped both languages by using 4 tasks: 1) English visual naming, 2) Hebrew visual naming, 3) read English/respond Hebrew, and 4) Hebrew reading. Essential cortical sites for primary and secondary languages were compared, photographically recorded, and plotted onto a schematic brain of the patient. Three types of sites were found in this patient: 1) multiuse sites (multiple tasks, both languages) in frontal, temporal, and parietal areas; 2) single-task sites (1 task, both languages) in postcentral and parietal areas; and 3) single-use sites (1 task, 1 language) in frontal, temporal, and parietal areas. These results lend support to the concept that bilingual patients can have distinct cortical representations of each language and of different language tasks, in addition to overlapping or shared sites that support both languages and multiple tasks.

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Renee M. Reynolds, Elizabeth Boswell, Christine M. Hulette, Thomas J. Cummings, Michael M. Haglund, Elizabeth Boswell, Christine M. Hulette, Thomas J. Cumm ings and Michael M. Haglund

In this paper the authors describe the rare disorder of diffuse leptomeningeal oligodendrogliomatosis in a patient with an oligodendroglioma of the cauda equina who died suddenly. Reviewing this uncommon pathological entity is important so that it can be recognized and treated appropriately. This young, otherwise healthy woman with initial symptoms of low-back pain had a mass lesion of the cauda equina. During a workup, profound refractory intracranial hypertension suddenly developed despite aggressive surgical and medical intervention. Autopsy revealed a spinal cord oligodendroglioma with diffuse leptomeningeal oligodendrogliomatosis of the brain and spinal cord. Given the unforeseen outcome in this patient, this entity, although rare, should be considered in patients with similar presentations and addressed early to prevent similar outcomes. A review of the details of this case as well as the literature is presented below.

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Mitchel S. Berger, Saadi Ghatan, Michael M. Haglund, Jill Dobbins and George A. Ojemann

✓ Adults and children with low-grade gliomas often present with medically refractory epilepsy. Currently, controversy exists regarding the need for intraoperative electrocorticography (ECoG) to identify and, separately, resect seizure foci versus tumor removal alone to yield maximum seizure control in this patient population. Forty-five patients with low-grade gliomas and intractable epilepsy were retrospectively analyzed with respect to preoperative seizure frequency and duration, number of antiepileptic drugs, intraoperative ECoG data (single versus multiple foci), histology of resected seizure foci, and postoperative control of seizures with or without antiepileptic drugs.

Multiple versus single seizure foci were more likely to be associated with a longer preoperative duration of epilepsy. Of the 45 patients studied, 24 were no longer taking antiepileptic drugs and were seizure-free (mean follow-up interval 54 months). Seventeen patients, who all had complete control of their seizures, remained on antiepileptic drugs at lower doses (mean follow-up interval 44 months); seven of these patients were seizure-free postoperatively, yet the referring physician was reluctant to taper the antiepileptic drugs. Four patients continued to have seizures while receiving antiepileptic drugs, although at a reduced frequency and severity. In this series 41% of the adults versus 85% of the children were seizure-free while no longer receiving antiepileptic drugs, with mean postoperative follow-up periods of 50 and 56 months, respectively. This difference was statistically significant (p = 0.016). Therefore, based on this experience and in comparison with numerous retrospective studies involving similar patients, ECoG is advocated, especially in children and in any patient with a long-standing seizure disorder, to maximize seizure control while minimizing or abolishing the need for postoperative antiepileptic drugs.

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Charles L. Branch Jr., Frederick Boop, Michael M. Haglund and Robert J. Dempsey

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David Kitya, Maria Punchak, Jihad Abdelgadir, Oscar Obiga, Derek Harborne and Michael M. Haglund

OBJECTIVE

Causes, clinical presentation, management, and outcomes of chronic subdural hematoma (CSDH) in low- and middle-income countries are not well characterized in the literature. Knowledge regarding these factors would be beneficial in the development and implementation of effective preventive and management measures for affected patients. The authors conducted a study to gain a better understanding of these factors in a low-income setting.

METHODS

This prospective study was performed at Mbarara Regional Referral Hospital (MRRH) in Uganda between January 2014 and June 2017. Patients of any age who presented and were diagnosed with CSDH during the aforementioned time period were included in the study. Variables were collected from patients’ files at discharge and follow-up clinic visits. The primary outcome of interest was death. Secondary outcomes of interest included discharge Glasgow Coma Scale (GCS) score, ICU admission, wound infection, and CSDH recurrence.

RESULTS

Two hundred five patients, the majority of whom were male (147 [72.8%]), were enrolled in the study. The mean patient age was 60.2 years (SD 17.7). Most CSDHs occurred as a result of motor vehicle collisions (MVCs) and falls, 35.6% (73/205) and 24.9% (51/205), respectively. The sex ratio and mean age varied depending on the mechanism of injury. Headache was the most common presenting symptom (89.6%, 173/193), whereas seizures were uncommon (11.5%, 23/200). Presenting symptoms differed by age. A total of 202 patients underwent surgical intervention with burr holes and drainage, and 22.8% (46) were admitted to the ICU. Two patients suffered a recurrence, 5 developed a postoperative wound infection, and 18 died. Admission GCS score was a significant predictor of the discharge GCS score (p = 0.004), ICU admission (p < 0.001), and death (p < 0.001).

CONCLUSIONS

Trauma from an MVC is the commonest cause of CSDH among the young. For the elderly, falling is common, but the majority have CSDH with no known cause. Although the clinical presentation is broad, there are several pronounced differences based on age. Burr hole surgery plus drainage is a safe and reliable intervention. A low preoperative GCS score is a risk factor for ICU admission and death.

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Michael M. Haglund, Joseph R. Meno, Daryl W. Hochman, Al C. Ngai and H. Richard Winn

Object

This study was undertaken to test the hypothesis that cerebral blood flow (CBF) and the intrinsic optical signal could be dissociated by altering adenosine receptor activity and to uncover the origin of the optic signal using a cranial window in the anesthetized rat.

Methods

In anesthetized, ventilated, and temperature-controlled rats with closed cranial windows, the authors evaluated simultaneously the alterations in pial arteriolar diameter, intrinsic optical signals (690 nm), and somatosensory evoked potentials during cortical activation evoked by contralateral sciatic nerve stimulation (SNS). To dissociate the vascular and intrinsic signal, they topically applied the adenosine receptors antagonists theophylline (5 μM), which affects A1 and A2A receptors, and 8-cyclopentyl-1,3-dipropylxanthine (CPX, 1 μM), which blocks the A1 receptor. The former interacts primarily with the vasculature whereas the latter influences the parenchyma exclusively.

Results

During 20 seconds of contralateral SNS, pial arterioles in the hindlimb somatosensory cortex dilated in a characteristic peak and shoulder pattern. As compared with mock cerebrospinal fluid alone, theophylline significantly (p < 0.05) attenuated SNS-induced vasodilation (mean ± standard deviation 8.1 ± 2.5% vs 21.7 ± 1.9%; 4 rats in each group). In contrast, CPX potentiated vasodilation significantly (p < 0.05) during SNS (54.7 ± 15.8% for the CPX group vs 20.1 ± 1.9% for the controls; 5 rats in each group).

The change in optical signal persisted after cessation of SNS in all the animals. Thus, the pattern of change of the optical signal was distinctly different from the pattern of changes in arteriolar diameter (which returned rapidly to baseline). Moreover, the optical signal during SNS was increased by 50% by theophylline and by almost 5-fold by CPX (p < 0.05). The area of change of the intrinsic signal was also increased by the topical application of theophylline and CPX.

The somatosensory evoked potential recordings revealed no significant changes after theophylline application, but CPX caused a small diminution of the N1 wave (p < 0.01).

Conclusions

The noncongruent temporal profiles of the changes in pial arteriolar diameter and optical signal, imaged at 690 nm, indicate that the optical signal at 690 nm is not related to CBF. Alteration of adenosine receptor activity independently changed cortical activity, as measured by the optical signal, and CBF, as determined by pial arteriolar diameter. Manipulation of the adenosine receptor activity during increased cortical activity confirmed the temporal dissociation of optical signal and CBF and provided further evidence for the role of adenosine in regulating CBF.

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Guy M. McKhann II, Julie Schoenfeld-McNeill, Donald E. Born, Michael M. Haglund and George A. Ojemann

Object. Among the variety of surgical procedures that are performed for the treatment of medically refractory mesial temporal lobe epilepsy (TLE), no consensus exists as to how much of the hippocampus should be removed. Whether all patients require a maximal hippocampal resection has not yet been determined.

Methods. At the University of Washington, all TLE operations are performed in a tailored fashion, guided by electrocorticography (ECoG). The amount of hippocampal resection is determined intraoperatively by the extent of interictal epileptiform abnormalities on ECoG recorded from that structure, resulting in a hippocampal resection that is individualized for each patient. Using this approach, the authors prospectively observed 140 consecutive patients who underwent surgery for mesial TLE with pathological diagnoses of either mesial temporal sclerosis with neuronal loss (MTS group) or mild gliosis without neuronal loss (non-MTS group) to determine whether the extent of hippocampal resection correlates with outcome when a tailored approach is used. Additionally, the authors analyzed whether the presence of residual interictal epileptiform activity on ECoG following mesial temporal resection predicts poorer seizure control.

With at least 18 months of clinical follow up, 67% of the 140 patients were seizure free or had only a single postoperative seizure. There was no correlation between the size of the hippocampal resection and seizure control in the group as a whole or when stratified by pathological subtype. Using an intraoperatively tailored strategy, individuals with a larger hippocampal resection (> 2.5 cm) were not more likely to have seizure-free outcomes than patients with smaller resections (p = 0.9). Additionally, both MTS and non-MTS patients, in whom postoperative ECoG detected residual epileptiform hippocampal (but not cortical or parahippocampal) interictal activity following surgical resection, had significantly worse seizure outcomes (p = 0.01 in the MTS group; p = 0.002 in the non-MTS group).

Conclusions. Intraoperative hippocampal ECoG can predict how much hippocampus should be removed to maximize seizure-free outcome, allowing for sparing of possibly functionally important hippocampus.

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John H. Sampson, Michael M. Haglund, Allan H. Friedman and Matthew G. Ewend