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John R. Taylor, William E. Bell and Carl J. Graf

✓ Cardiomegaly secondary to a cerebrovascular malformation is described in a 4-year-old child, including resolution of the cardiomegaly following successful removal of the malformation. The pathophysiological mechanisms are discussed, as well as the care of such patients during and immediately after surgery. All patients with large vascular malformations should have careful assessment of their cardiac status, and, conversely, the evaluation of patients with unexplained cardiomegaly or heart failure should include a search for vascular malformations.

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William A. S. Taylor, David Uttley and P. R. Wilkins

✓ Only 12 cases of pituitary tumors that metastasized within the central nervous system have been reported. A further case is presented in which the histology of the multiple dural metastases remained identical to that of the original tumor, a pituitary adenoma. The authors discuss management of these rare lesions that appear histologically benign.

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Edward R. Laws Jr., William F. Taylor, Marvin B. Clifton and Haruo Okazaki

✓ The authors conducted a retrospective review of surgically treated, histologically proven cases of low-grade (Grade 1 or 2) astrocytomas. Follow-up analysis, with survival time as the end-point, was completed using multivariant statistical analysis. In the 461 cases of supratentorial low-grade astrocytoma in this study, age of the patient at the time of surgery was by far the most important variable in predicting length of survival. Other variables correlating with increasing survival times were: gross total surgical removal, lack of major preoperative neurological deficit, long duration of symptoms prior to surgery, seizures as a presenting symptom, lack of major postoperative neurological deficit, and surgery performed in recent decades. The multi-variant regression analysis showed that radiation therapy was of clear benefit, primarily in older patients with incompletely removed tumors.

For purposes of establishing prognosis and testing the results, a “score” was developed to predict survival times, based on the most important variables. The data in this study provide a basis for the analysis of future modes of management of low-grade gliomas.

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Anterior sacral meningocele associated with a rectal fistula

Case report and review of the literature

Michael Owen Fitzpatrick and William A. S. Taylor

✓ The authors report a case of anterior sacral meningocele associated with a rectal fistula in a patient who had presented 20 years earlier with bacterial meningitis. To their knowledge, this is the first case in which a rectal fistula developed due to an anterior sacral meningocele. The clinical presentation, diagnosis, and treatment of this uncommon lesion is discussed.

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Frank L. Acosta Jr., Henry E. Aryan, William R. Taylor and Christopher P. Ames

Object

Surgical intervention for thoracolumbar burst fractures is indicated for patients with neurological deficits and/or evidence of severe spinal instability. The goals of surgery are decompression, deformity correction, and stabilization. Nevertheless, the optimal surgical strategy to achieve these goals remains a subject of debate. Short-segment pedicle screw fixation is associated with a 20 to 50% incidence of pedicle screw failure and progressive spinal deformity. Initial biomechanical and clinical studies have shown that reinforcement of short-segment pedicle screw fixation with vertebroplasty improves spinal stability and decreases instrument failure rates. In this study, the authors describe their initial clinical experience with kyphoplasty used to augment short-segment pedicle screw fixation of traumatic lumbar burst fractures.

Methods

Five patients with traumatic burst fractures of the lumbar spine were included in this retrospective review of patients treated for this disorder at the University of California, San Diego and the University of California, San Francisco between 2002 and 2004. All patients underwent transpedicular kyphoplasty and short-segment pedicle screw fixation. The mean follow-up period was 10.6 months (range 6–18 months). All patients underwent short-segment pedicle screw fixation reinforced with polymethyl methacrylate kyphoplasty. The preoperative, postoperative, and follow-up plain x-ray films were evaluated. Radiographic analysis included measurements of kyphotic angulation, anterior vertebral body height, and evidence of bone fusion. Clinical evaluation was performed postoperatively and at follow-up review.

Conclusions

Based on the authors' initial experience, kyphoplasty supplementation may improve the long-term integrity of short-segment pedicle screw constructs and allow for improved rates of fusion and better clinical outcomes in patients with traumatic lumbar burst fractures.

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William Taylor, J. Douglas Miller and Nicholas V. Todd

✓ The long-term prognosis (15 years) was determined for 17 patients who had undergone anterior cerebral artery (ACA) ligation as the sole treatment for an anterior communicating artery aneurysm. The number of early and late rebleeds was lower than expected from previously ruptured aneurysms. Late ischemia was not a major complication while late postoperative epilepsy occurred in 19% of survivors. In a review of previously published series, ACA ligation appears to have significantly reduced the rates of both early and late rebleeding. This study helps to define the late results of “conservative” operations for ruptured aneurysms.

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J. Brian North, Robert K. Penhall, Ahmad Hanieh, Derek B. Frewin and William B. Taylor

✓ A double-blind trial of phenytoin therapy following craniotomy was performed to test the hypothesis that phenytoin is effective in reducing postoperative epilepsy. A significant reduction in the frequency of epilepsy was observed in the group receiving the active drug up to the 10th postoperative week. Half of the seizures occurred in the first 2 weeks and two-thirds within 1 month of cranial surgery. High rates of epilepsy were observed after surgery in patients with meningioma, metastasis, aneurysm, and head injury.

Routine prophylaxis with phenytoin (in a dosage of 5 to 6 mg/kg/day) would seem to be indicated, particularly in high-risk patients and, where possible, this treatment should be started 1 week preoperatively. Seizure control is best when therapeutic levels of phenytoin are maintained.

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William A. S. Taylor, Nicholas W. M. Thomas, Julia A. Wellings and B. Anthony Bell

✓ This study records the incidence and timing of postoperative hematomas in neurosurgical patients and analyzes the best use of neurosurgical intensive care. In 2305 patients undergoing freehand or stereotactic biopsy, elective or emergency craniotomy, or posterior fossa surgery, 50 (2.2%) developed a hematoma. Clinical deterioration as a result of postoperative hematoma occurred within 6 hours of surgery in 44 patients and more than 24 hours after surgery in six patients. Although patients undergoing posterior fossa surgery or emergency craniotomy warrant longer periods of intensive-care observation, patients having elective supratentorial operations can safely be transferred to a neurosurgical ward for observation, provided they have regained their preoperative neurological status by 6 hours postsurgery.

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Pawel P. Jankowski, Lissa C. Baird, Sassan Keshavarzi, Mary E. Goolsby, William R. Taylor and Andrew D. Nguyen

The authors describe here a unique case of contiguous, synchronous meningioma and lymphoma in the spinal column. Both tumors were present at the same vertebral level, one intradural and the other extradural. A patient presented with bilateral leg pain, acute weakness, and sensory loss in the lower extremities. Magnetic resonance imaging revealed an intradural mass at T6–7 with ambiguous boundaries relative to the thecal sac and compressing the spinal cord. The patient underwent resection of the epidural and intradural mass at T6–7. Histopathology revealed the epidural specimen to be a double-hit B-cell lymphoma and the intradural mass to be a transitional meningioma. Postoperatively, the patient did well, with an immediate return of strength and sensation. A postoperative MR image showed complete resection of the intradural mass. The authors suggest that biopsy may be prudent in patients with known systemic lymphoma presenting with a spinal lesion that has unclear boundaries relative to the thecal sac prior to commencing radiation and chemotherapy.

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G. Bryan Cornwall, Donna L. Wheeler, Kevin A. Thomas, William R. Taylor and A. Simon Turner

Object. Iliac crest bone graft harvesting can result in major complications, the rates of which range from approximately 6 to 8%. The objective of this study was to evaluate the postoperative regeneration of iliac crest donor defects in an animal model after harvesting a full-thickness tricortical graft.

Methods. In skeletally mature sheep, a tricortical iliac crest graft was harvested. The graft sites were allowed to heal unprotected or protected with the resorbable polylactic acid sheet material, MacroPore OS Protective Sheeting. After 6 months of healing, the sites were assessed by examination of undecalcified histological sections. Histomorphometric measurements of the original defect area, the area of new bone within the defect site, and the percentage of defect filled with new bone were quantified for both control and protected groups. In all histological sections, new bone growth within the defect sites appeared normal, with no observed excessive inflammatory cells. The developing bone tissue appeared to be remodeling normally. For the unprotected sites, the area of new bone averaged 16.3 mm2 (± 7.2 mm2), and the percentage of the defect area filled with bone averaged 10.7% (± 6.5%). In the protected sites, the area of new bone averaged 64.8 mm2 (± 11.6 mm2) and the percentage of the defect area filled with bone averaged 25.9% (± 1.6%). Both differences in area of new bone growth and percentage of defect area filled were statistically significant. Literature review has indicated that regeneration of donor site defects is desirable.

Conclusions. Based on the results of the present study, MacroPore resorbable Protective Sheeting can improve bone regeneration significantly within the donor site following tricortical iliac crest graft harvesting.