Search Results

You are looking at 1 - 10 of 23 items for

  • Author or Editor: Sanford Roberts x
Clear All Modify Search
Restricted access

Robert A. Sanford

The author describes 2 cases of children with growing skull fractures (GSFs). Surgical exploration of the widened fracture shortly after the head injury failed to reveal a dural tear because the neuroimaging studies (MR images, CT scans, and skull radiographs) had not been accurately interpreted, thereby allowing the development of a GSF at the site of the actual dural injury. In both cases, the dural and bony defect and the leptomeningeal cyst were successfully repaired.

To prevent GSFs associated with progressive neurological deficit, seizure, ventricular porencephaly, and encephalomalacia, the author surgically explores wide skull fractures in young children with head injury whose MR images demonstrate brain herniation through the dura mater. The importance of a brief delay in surgical exploration is emphasized to allow cerebral edema to resolve and the patient's condition to become medically stabilized.

Restricted access

Robert A. Sanford and Robert A. Smith

✓ Solid hemangioblastomas of the cervicomedullary junction are benign vascular neoplasms malignantly located. Their unusual and characteristic clinical presentations include loss of involuntary respiratory drive, neurogenic hypertension, and emesis; these are secondary to their involvement of the tractus solitarius in the medulla. Although angiography is diagnostic, the computerized tomography appearance and unusual location also suggest the diagnosis. The correct preoperative diagnosis is particularly important for the successful surgical excision of these vascular tumors. The microsurgical removal of cervicomedullary hemangioblastomas is described in three patients.

Restricted access

Robert A. Sanford, Jose Bebin and R. Wayne Smith

✓ The authors present the cases of two young adults with low-grade astrocytomas limited to the aqueductal region of the tectum of the mesencephalon. The characteristic presentation of hydrocephalus without brain-stem signs is described. Careful radiological examination, including computerized axial tomography, failed to reveal any evidence of tumor. The diagnosis was established at postmortem examination. Literature review yielded 12 previous cases of similar presentation.

Restricted access

Steven L. Klein, Robert A. Sanford and Michael S. Muhlbauer

✓ A total of 2259 children with solid malignant tumors were treated at St. Jude Children's Research Hospital between the years 1962 and 1987. Of these, 112 (5%) developed spinal epidural metastasis with spinal cord compression during the course of their disease process. Metastatic epidural spinal cord compression was caused most commonly by Ewing's sarcoma and neuroblastoma, followed by osteogenic sarcoma, rhabdomyosarcoma, Hodgkin's disease, soft-tissue sarcoma, germ-cell tumor, Wilm's tumor, and (rarely) hepatoma. There was no significant difference in outcome between patients with small-cell tumors (neuroblastoma, Hodgkin's disease, and germ-cell tumors) who received only chemotherapy and/or radiation therapy and the patients with similar lesions who received a decompressive laminectomy alone or prior to chemotherapy and/or radiation therapy. Patients with spinal cord compression from metastatic sarcoma (Ewing's sarcoma, soft-tissue sarcoma, osteogenic sarcoma, and rhabdomyosarcoma) showed a significant improvement with decompressive laminectomy alone or before medical therapy, compared to those who received radiation therapy and/or chemotherapy without posterior decompression.

Pediatric tumors invade the spinal canal via the neural foramen, compressing the spinal cord in a circumferential manner, allowing decompressive laminectomy (posterior approach) to be an effective surgical approach. Sixty-six percent of children who had no evidence of motor or sensory function below the level of the compression became ambulatory after surgical decompression and medical treatment, regardless of tumor type.

Restricted access

Joseph F. Cusick, Sanford J. Larson, Patrick R. Walsh and Robert E. Steiner

✓ Stabilization of the spinal column with Harrington distraction rods and acrylic fusion was the primary form of treatment in a select group of patients with metastatic carcinoma of the spinal column. Clinical criteria included patients in poor general medical condition with intractable pain originating from metastatic tumor involvement in the ventral components of the thoracic or upper lumbar spinal column and minimal evidence or absence of spinal cord compression. After stabilization, pain relief was almost total and sustained, and neurological status generally remained unchanged from preoperative findings without any evidence of improvement of preexisting abnormalities or occasions of rapid neurological deterioration. This form of spinal stabilization may offer significant relief of debilitating pain, lessen the risk of pathological fracture-dislocation of the thoracic or upper lumbar vertebral column, and reduction in the local compressive effects on the spinal cord caused by ventrally situated metastatic tumor.

Restricted access

S. Jared Broadway, Robert J. Ogg, Matthew A. Scoggins, Robert Sanford, Zoltan Patay and Frederick A. Boop

Object

Thalamopeduncular tumors arise at the junction of the inferior thalamus and cerebral peduncle and present with a common clinical syndrome of progressive spastic hemiparesis. Pathologically, these lesions are usually juvenile pilocytic astrocytomas and are best treated with resection with the intent to cure. The goals of this study are to define a common clinical syndrome produced by thalamopeduncular tumors and to discuss imaging characteristics as well as surgical adjuncts, intraoperative nuances, and postoperative complications relating to the resection of these neoplasms.

Methods

The authors present a retrospective review of their experience with 10 children presenting between 3 and 15 years of age with a thalamopeduncular syndrome. Formal preoperative MR imaging was obtained in all patients, and diffusion tensor (DT) imaging was performed in 9 patients. Postoperative MR imaging was obtained to evaluate the extent of tumor resection. A prospective analysis of clinical outcomes was then conducted by the senior author.

Results

Pilocytic astrocytoma was the pathological diagnosis in 9 cases, and the other was fibrillary astrocytoma. Seven of 9 pilocytic astrocytomas were completely resected. Radical surgery was avoided in 1 child after DT imaging revealed that the corticospinal tract (CST) coursed through the center of the tumor, consistent with the infiltrative nature of fibrillary astrocytoma as identified by stereotactic biopsy. In 8 patients, tractography served as an important adjunct for designing a surgical approach that spared the CST. In 6 cases the CSTs were pushed anterolaterally, making a transsylvian approach a poor choice, as was evidenced by the first patient in the series, who underwent operation prior to the advent of tractography, and who awoke with a dense contralateral hemiparesis. Thus, subsequent patients with this deviation pattern underwent a transcortical approach via the middle temporal gyrus. One patient exhibited medial deviation of the tracts and another had lateral deviation, facilitating a transtemporal and a transfrontal approach, respectively.

Conclusions

The thalamopeduncular syndrome of progressive spastic hemiparesis presenting in children with or without symptoms of headache should alert the examiner to the possibility of a tumoral involvement of CSTs. Preoperative tractography is a useful adjunct to surgical planning in tumors that displace motor pathways. Gross-total resection of pilocytic astrocytomas usually results in cure, and therefore should be entertained when developing a treatment strategy for thalamopeduncular tumors of childhood.

Restricted access

Evgeny E. Kyrnetskiy, Larry E. Kun, Frederick A. Boop, Robert A. Sanford and Raja B. Khan

Object. The aim of this study was to investigate the cause and outcome of intracranial hemorrhage (ICH) in children with cancer.

Methods. The charts of 51 children who underwent treatment for both cancer and ICH between January 1985 and January 2003 were retrospectively reviewed. Assessment tools included the Karnofsky Performance Scale (KPS), Glasgow Coma Scale (GCS), and the Fisher exact and Student t-tests.

Among the 51 cases, 30 involved brain tumors, 19 leukemia, and two lymphoma. The treatment group (Group 1) comprised 36 patients who suffered ICH during cancer treatment; the posttreatment group (Group 2) consisted of the 15 patients who suffered ICH after the completion of cancer treatment. The types of ICH included 22 cortical, four subcortical, 17 subdural, five brainstem, one subarachnoid, one epidural, and one ventricular. Thrombocytopenia was present in nine patients (25%) in Group 1. More patients in Group 2 (87%) than in Group 1 (44%) underwent cranial radiation treatment. Patients in Group 1 experienced a higher incidence of coagulopathy (37%) and ICH-related death (25%) than those in Group 2 (0 and 7%, respectively). Decrease in KPS and GCS scores of greater than 30 and greater than 3, respectively, at the time of ICH were indicators of increased mortality. Of the 17 children with subdural ICH, 13 suffered the hemorrhage following treatment for hydrocephalus and three patients suffered ICH associated with thrombocytopenia. In the 33 children alive at the 3-month follow-up examination after the ICH, no difference existed in the mean KPS scores pre- and post-ICH.

Conclusions. Treatment for hydrocephalus, coagulopathy, thrombocytopenia, and hemorrhage into the tumor were the most probable causes of ICH among patients in Group 1. Radiation-induced vasculopathy was a possible cause of ICH in the patients in Group 2. Significant decline in the patient's neurological status at the time of ICH is a poor prognostic factor, but those patients who survive cancer and ICH are likely to regain neurological function.

Restricted access

Raja B. Khan, Frederick A. Boop, Arzu Onar and Robert A. Sanford

Object

The goals of this study were to define the incidence of seizures in children with low-grade tumors, study seizure outcome after lesionectomy in these children, and identify risk factors for poor seizure outcome.

Methods

The authors performed a retrospective chart review of children who harbored low-grade brain tumors, experienced seizures, and were treated in a single institution. Statistical analyses included step-wise as well as single-variable binary logistic regression analyses.

Fifty-five children (20%) with seizures were identified in a cohort of 280 children with low-grade tumors. Of these 55 children, 35 harbored cortical cerebral tumors and 20 had noncortical lesions, including six whose tumors were in the posterior fossa. Seizures were defined as controlled if there was no seizure in the 12 months preceding the last clinic visit. All cortical tumors were treated by lesionectomy as an initial procedure. Of the 27 children with cortical tumors whose seizures began before tumor diagnosis, 23 had complete resection and 52% of these 23 experienced no further seizures after surgery. Seizures are presently controlled in 84% of the total 55 patients at a median follow-up time of 4.5 years after the first seizure (range 1–17.4 years). Only two variables, a pericavity hyperintense signal on T2-weighted magnetic resonance (MR) images and at least 10 seizures prior to therapy for seizures, were associated with uncontrolled seizures.

Conclusions

Lesionectomy may be appropriate in children with low-grade brain tumors. A large number of seizures before therapy and a hyperintense area around the tumor cavity on postresection MR images are associated with uncontrolled seizures. Medical therapy and tumor resection will control seizures in the majority of children with low-grade tumors.

Restricted access

Sanford J. Larson, Robert A. Holst, David C. Hemmy and Anthony Sances Jr.

✓ The lateral extracavitary approach to the spine was used for resection of displaced bone and disc located anterior to the dura in 62 patients with traumatic lesions of the thoracic and lumbar spine. Fifty-two patients had closed vertebral fractures and 10 had gunshot wounds. The spinal cord was involved in 44 patients, and the cauda equina in 18. A spinal subarachnoid block was demonstrated in 17 of 57 preoperative gas myelograms. Evoked potential recordings, although related to perception of joint rotation, tended to reflect the overall neurological condition and had some prognostic value. Significant improvement followed surgery in 46 patients with incomplete neurological lesions, and one was transiently worse. Before operation 18 patients were able to walk; nine with assistance and nine without. After operation 47 patients were able to walk; 12 with assistance and 35 without. Adequate bladder function was present in 17 patients before surgery, and in 44 after surgery. A laminectomy had been done previously in 16 patients, 11 of whom improved significantly after anterior resection. Spine fusions were required in 26 patients, five of whom had a prior laminectomy. The major factor in the pathogenesis of the incomplete neurological deficit appeared to be distortion of the cord and roots by displaced bone and disc. Consequently, the primary object of treatment was the restoration and maintenance of normal anatomical relationships between the spinal cord or cauda equina and the spinal canal.

Restricted access

Julian Lin, Martin Morris, William Olivero, Frederick Boop and Robert A. Sanford

✓ The treatment of hydrocephalus with shunt insertion is fraught with high failure rates. Evidence indicates that the proximal holes in a catheter are the primary sites of blockage. The authors have studied ventricular catheter designs by using computational fluid dynamics (CFD), two-dimensional water table experiments, and a three-dimensional (3D) automated testing apparatus together with an actual catheter. With the CFD model, the authors calculated that 58% of the total fluid mass flows into the catheter's most proximal holes and that greater than 80% flows into the two most proximal sets of holes within an eight-hole catheter. In fact, most of the holes in the catheters were ineffective. These findings were experimentally verified using two completely different methodologies: a water table model of a shunt catheter and a 3D automated testing apparatus with an actual catheter to visualize flow patterns with the aid of ink. Because the majority of flow enters the catheter's most proximal holes, blockages typically occur at this position, and unlike blockages at distal holes, occlusion of proximal holes results in complete catheter failure. Given this finding, new designs that incorporated varying hole pattern distributions and size dimensions of the ventricular catheter were conceived and tested using two models. These changes in the geometrical features significantly changed the entering mass flow rate distribution. In conclusion, new designs in proximal ventricular catheters with variable hole diameters along the catheter tip allowed fluid to enter the catheter more uniformly along its length, thereby reducing the probability of its becoming occluded.