✓ A syndrome of dorsal midbrain dysfunction in association with a central nervous system anaerobic diphtheroid infection is described. Two cases of infection with Propionibacterium acnes manifested as shunt malfunctions with a clinical dorsal midbrain syndrome. Magnetic resonance images showed increased signal in the midbrain tectum which has decreased slowly over time. The evidence suggesting that this syndrome represents bacterial midbrain encephalitis is discussed.
Report of two cases
Paul J. Camarata, Robert E. McGeachie and Stephen J. Haines
Kyle A. Smith, Michael Salacz and Paul J. Camarata
Sindhura Pisipati, Kyle A. Smith, Kushal Shah, Koji Ebersole, Roukoz B. Chamoun and Paul J. Camarata
Laser interstitial thermal therapy (LITT) is used in numerous neurosurgical applications including lesions that are difficult to resect. Its rising popularity can be attributed to its minimally invasive approach, improved accuracy with real-time MRI guidance and thermography, and enhanced control of the laser. One of its drawbacks is the possible development of significant edema, which contributes to extended hospital stays and often necessitates hyperosmolar or steroid therapy. Here, the authors discuss the use of minimally invasive craniotomy to resect tissue ablated with LITT in attempt to minimize cerebral edema.
Five patients with glioblastoma multiforme prospectively underwent LITT followed by resection. The LITT was performed with the aid of an MR-compatible skull-mounted frame in the MRI suite. Ablated tumor was then resected via small craniotomy by using the NICO Myriad system or cavitron ultrasonic surgical aspirator. Postoperative management involved dexamethasone administration slowly tapered over several weeks.
The use of resection following LITT, as compared with open resection or LITT alone, did not extend the hospital stay except in 1 patient who required 3-day inpatient management of edema with a trapped ventricle. No new neurological deficits were encountered, although 1 patient developed seizures postoperatively. No increase in infection rates was identified.
Resection of ablated tumor is a viable option to reduce the incidence of neurological deficits due to edema following LITT. This approach appears to mitigate cerebral edema by increasing available volume for mass effect and reducing the tissue burden that may promote an inflammatory response.
Kyle A. Smith, John D. Leever, Phillip D. Hylton, Paul J. Camarata and Roukoz B. Chamoun
Meningioma consistency, firmness or softness as it relates to resectability, affects the difficulty of surgery and, to some degree, the extent of resection. Preoperative knowledge of tumor consistency would affect preoperative planning and instrumentation. Several methods of prediction have been proposed, but the majority lack objectivity and reproducibility or generalizability to other surgeons. In a previous pilot study of 20 patients the authors proposed a new method of prediction based on tumor/cerebellar peduncle T2-weighted imaging intensity (TCTI) ratios in comparison with objective intraoperative findings. In the present study they sought validation of this method.
Magnetic resonance images from 100 consecutive patients undergoing craniotomy for meningioma resection were evaluated preoperatively. During surgery a consistency grade was prospectively applied to lesions by the operating surgeon, as determined by suction and/or cavitron ultrasonic surgical aspirator (CUSA) intensity. Consistency grades were A, soft; B, intermediate; and C, fibrous. Using T2-weighted MRI sequences, TCTI ratios were calculated. Analysis of the TCTI ratios and intraoperative tumor consistency was completed with ANOVA and receiver operating characteristic curves.
Of the 100 tumors evaluated, 50 were classified as soft, 29 as intermediate, and 21 as firm. The median TCTI ratio for firm tumors was 0.88; for intermediate tumors, 1.5; and for soft tumors, 1.84. One-way ANOVA comparing TCTI ratios for these groups was statistically significant (p < 0.0001). A single cutoff TCTI value of 1.41 for soft versus firm tumors was found to be 81.9% sensitive and 84.8% specific.
The authors propose this T2-based method of tumor consistency prediction with correlation to objective intraoperative consistency. This method is quantifiable and reproducible, which expands its usability. Additionally, it places tumor consistency on a graded continuum in a clinically meaningful way that could affect preoperative surgical planning.
Kiyoyuki Yanaka, Stephen R. Spellman, James B. McCarthy, Walter C. Low and Paul J. Camarata
✓ The administration of massive doses of heparin has been demonstrated to reduce reperfusion injury. The authors have found that heparin's antileukocyte adhesion property may play a more important role than its anticoagulant property in preventing ischemia and reperfusion injury. Although the administration of massive doses of heparin has been demonstrated to reduce brain injury after ischemia and reperfusion, the optimum dosage and timing for heparin administration remain unknown. The purpose of this study was to evaluate the dose—response effect and determine the time during which heparin must be administered to inhibit leukocyte accumulation, reduce infarct size, and improve neurological outcome in rats subjected to 1 hour of cerebral ischemia and 48 hours of reperfusion. Forty-nine animals were included in the study. The animals receiving commercial unfractionated heparin at a total dose of 2.67 to 4 mg/kg showed a significant inhibition of leukocyte accumulation, reduced infarct size, and lessened neurological dysfunction 48 hours after reperfusion (p < 0.05) when compared to untreated animals. The animals receiving unfractionated heparin within 3 hours after reperfusion also showed significantly better results than untreated animals. These data indicate that standard doses of heparin prevent reperfusion injury, and relatively late postischemic administration of heparin also is effective in brain protection. These findings may have therapeutic potential as an adjunct to thrombolytic therapy and possibly for other perfusion deficiencies with leukocyte—endothelial interaction. In view of these encouraging experimental findings, the clinical application of heparin administration after ischemia and reperfusion warrants serious consideration.
Kiyoyuki Yanaka, Paul J. Camarata, Stephen R. Spellman, James B. McCarthy, Leo T. Furcht, Walter C. Low and Roberto C. Heros
✓ Leukocytes play an important role in the development of ischemia—reperfusion injury. This study was conducted to ascertain whether synthetic peptides corresponding to the cell- and heparin-binding sequences of fibronectin that disturb leukocyte adhesion molecules were effective in neuronal protection after transient focal cerebral ischemia in rats. The authors evaluated the efficacy of peptides on infarction size, leukocyte infiltration in the ischemic tissue, and neurological outcome in rats subjected to 1 hour of cerebral ischemia and 48 hours of reperfusion. Twenty-one animals were divided into three groups: transient ischemia without treatment (Group I), transient ischemia with administration of vehicle (Group II), and transient ischemia with administration of fibronectin peptides (Group III). The mean myeloperoxidase activity (U/g wet wt) in the ischemic area was as follows: Group I, 0.19% ± 0.05; Group II, 0.21% ± 0.03; and Group III, 0.08% ± 0.02. The mean size of the infarction as a percentage of the total hemispheric volume was as follows: Group I, 38.35% ± 1.34%; Group II, 39.21% ± 2.42%; and Group III, 25.81% ± 4.87%. Group III showed a significant decrease in myeloperoxidase activity in the lesion and the infarction size was smaller when compared to Groups I and II (p < 0.05). The neurological grade in Group III was significantly better than in Groups I and II at 48 hours after reperfusion (p < 0.01). This study is the first to explore the therapeutic potential of synthetic fibronectin peptides in brain protection after transient focal ischemia, and the results also serve as a basis for studies of important cellular and molecular events that contribute to tissue damage.
Kiyoyuki Yanaka, Stephen R. Spellman, James B. McCarthy, Theodore R. Oegema Jr., Walter C. Low and Paul J. Camarata
✓ Heparin has long been established as an anticoagulant. Although heparin has been demonstrated to reduce brain injury after ischemia and reperfusion, its mechanism of action remains unknown. Recent investigations reveal that it can modulate biological processes such as binding to adhesion receptors on endothelial cells and leukocytes. The authors hypothesized that heparin's protective effect is closely related to its antileukocyte adherence property. They evaluated the efficacy of sulfated polysaccharides (unfractionated heparin, low-molecular-weight heparin, heparan sulfate, chondroitin sulfate C, and dextran sulfate) on leukocyte accumulation, infarction size, and neurological outcome after transient focal cerebral ischemia in rats subjected to 1 hour of ischemia and 48 hours of reperfusion. Forty-nine animals were included in the study. The animals receiving unfractionated heparin or dextran sulfate showed a significant reduction in leukocyte accumulation, infarct size, and neurological dysfunction 48 hours after reperfusion (p < 0.05) when compared to untreated animals. The animals receiving unfractionated heparin also showed significantly better results than the animals receiving an equivalent anticoagulant dose of low-molecular-weight heparin. These data indicate that heparin's antileukocyte property plays a more important role than its anticoagulant ability in neuronal protection. The relative potency of the sulfated polysaccharides tested in leukocyte depletion was closely related to their degree of sulfation. Thus, in addition to demonstrating the potential efficacy of heparin as a therapeutic agent for ischemia and reperfusion injury by the prevention of leukocyte accumulation, the results also serve as a basis for studying important cellular and molecular events that contribute to tissue damage.