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Richard Whitehill, Anthony D. Cicoria, William E. Hooper, William W. Maggio, and John A. Jane

✓ The charts and radiographs of 20 patients who were treated for traumatic cervical instability by the Department of Neurosurgery at the University of Virginia by means of posterior reconstruction with methyl methacrylate cement and fixation wires were reviewed by the Department of Orthopaedic Surgery. Based primarily on radiographic criteria, it was found that posterior reconstruction failed to rigidly immobilize the underlying unstable motion segments in 11 patients. Four of these patients required additional surgery to correct postoperative instability. Based on this experience, cement and wire reconstructions are now recommended only when: 1) they can be limited to one cervical level; 2) No. 18 fixation wire is used; 3) wiring is performed from a facet on one side to the adjacent spinous processes; and 4) autogenous bone graft is added to the posterior elements on the side of the midline opposite the cement and wire.

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Austin R. T. Colohan, John A. Jane, Steven A. Newman, and William W. Maggio

✓ The authors have previously advocated a supraorbital approach to tumors of the orbit. In this paper, they describe a technique in which they take advantage of a large frontal sinus as a means of entering the orbit without the necessity of intracranial exposure, as required by the more conventional supraorbital approach. This is achieved without frontal burr holes, allowing for a superior cosmetic result. The anterior wall of the frontal sinus is removed, and with it the roof of the orbit as a single bone flap. A case in which this technique was used is described.

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Panagiotis G. Simos, Andrew C. Papanicolaou, Joshua I. Breier, James W. Wheless, Jules E. C. Constantinou, William B. Gormley, and William W. Maggio

Object. In this paper the authors demonstrate the concordance between magnetic source (MS) imaging and direct cortical stimulation for mapping receptive language cortex.

Methods. In 13 consecutive surgical patients, cortex specialized for receptive language functions was identified noninvasively by obtaining activation maps aided by MS imaging in the context of visual and auditory word-recognition tasks. Surgery was then performed for treatment of medically intractable seizure disorder (eight patients), and for resection of tumor (four), or angioma (one). Mapping of language areas with cortical stimulation was performed intraoperatively in 10 patients and extraoperatively in three. Cortical stimulation mapping verified the accuracy of the MS imaging—based localization in all cases.

Conclusions. Information provided by MS imaging can be especially helpful in cases of atypical language representation, including bihemispheric representation, and location of language in areas other than those expected within the dominant hemisphere, such as the anterior portion of the superior temporal gyrus, the posteroinferior portion of the middle temporal gyrus, the basal temporal cortex, and the lateral temporooccipital cortex.

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Anil A. Dhople, Jared R. Adams, William W. Maggio, Shahid A. Naqvi, William F. Regine, and Young Kwok

Object

Few long-term studies of Gamma Knife surgery (GKS) for trigeminal neuralgia (TN) exist. The authors report their long-term experience with the use of GKS in a previously reported cohort of patients with TN that has now been followed since 1996.

Methods

One hundred twelve patients with TN were treated with GKS at the University of Maryland between June 1996 and July 2001. Of these, 67% had no invasive operations for TN prior to GKS, 13% had 1, 4% had 2, and 16% had ≥ 3. The right side was affected in 56% of cases, predominantly involving V2 (26%), V3 (24%), or a combination of both (18%) branches. The median age at diagnosis was 56 years, and median age at GKS was 64 years. The median prescription dose of 75 Gy (range 70–80 Gy) was delivered to the involved trigeminal nerve root entry zone. The authors assessed the degree of pain before and after GKS by using the Barrow Neurological Institute (BNI) pain scale.

Results

In total, 102 patients took the survey at least once, for a response rate of 91%. Although not found to alter the conclusions of this study, 7 cases of atypical TN were found and these patients were removed, for a total of 95 cases herein analyzed. The median follow-up was 5.6 years (range 13–115 months). Before GKS, 88% of patients categorized their pain as BNI IV or V (inadequate control or severe pain on medication), whereas the remainder described their pain as BNI III (some pain, but controlled on medication). After GKS, 64% reported a BNI score of I (no pain, no medications), 5% had BNI II (no pain, still on medication), 12% had BNI III, and 19% reported a BNI score of IV or V. The median time to response was 2 weeks (range 0–12 weeks) and the median response duration was 32 months (range 0–112 months). Eighty-one percent reported initial pain relief, and actuarial rates of freedom from treatment failure at 1, 3, 5, and 7 years were 60, 41, 34, and 22%, respectively. Response duration was significantly better for those who had no prior invasive treatment versus those in whom a previous surgical intervention had failed (32 vs 21 months, p < 0.02). New bothersome facial numbness was reported in 6% of cases.

Conclusions

This study represents one of the longest reported median follow-up periods and actuarial results for a cohort of patients with classic TN treated with GKS. Although GKS achieves excellent rates of initial pain relief, these results suggest a steady rate of late failure, particularly among patients who had undergone prior invasive surgical treatment. Despite a higher than expected recurrence rate, GKS remains a viable treatment option, particularly for patients who have had no prior invasive procedures. Patients with recurrences can still be offered salvage therapy with either repeat GKS, microvascular decompression, or rhizotomy.

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Andrew C. Papanicolaou, Panagiotis G. Simos, Eduardo M. Castillo, Joshua I. Breier, Shirin Sarkari, Ekaterina Pataraia, Rebecca L. Billingsley, Scott Buchanan, James Wheless, Vijayalakshmi Maggio, and William W. Maggio

Object. In this study the authors evaluated the sensitivity and selectivity of a noninvasive language mapping procedure based on magnetoencephalography (MEG), for determining hemispheric dominance for language functions.

Methods. Magnetic activation profiles of the brain were obtained from 100 surgical candidates (age range 8–56 years) with medically intractable seizure disorder by using a whole-head MEG system within the context of a word recognition task. The degree of language-specific activity was indexed according to the number of consecutive sources (modeled as single, moving current dipoles) in perisylvian brain areas. Only activity sources that were observed with a high degree of spatial and temporal overlap in two split-half data sets were used to compute the MEG laterality index. Independently, all patients underwent Wada testing for the determination of hemispheric dominance for language.

Independent clinical judgments based on MEG and Wada data showed a high degree of concordance (87%). Magnetoencephalography laterality judgments had an overall sensitivity of 98%, but a lower selectivity of 83%, which was due to the fact that MEG detected more activity in the nondominant hemisphere than was predicted based on the Wada test. A number of objective criteria were derived based on this large patient series to ensure data quality and bolster the clinical usefulness of MEG for language mapping.

Conclusions. Although the availability of MEG is still limited across epilepsy surgery centers, this study method may be substituted for the Wada procedure in assessing hemispheric dominance for language in select cases.

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Panagiotis G. Simos, Eduardo M. Castillo, Jack M. Fletcher, David J. Francis, Fernando Maestu, Joshua I. Breier, William W. Maggio, and Andrew C. Papanicolaou

Object. There are conflicting claims in the functional imaging literature concerning whether different languages are represented by distinct brain mechanisms in individuals who are proficient in more than one language. This interesting theoretical issue has practical implications when functional imaging methods are used for presurgical language mapping. To address this issue the authors compared the location and extent of receptive language cortex specific to English and Spanish in neurologically intact bilingual volunteers by using magnetic source imaging.

Methods. Areas of the cortex that were specialized for receptive language functions were identified separately for each language in 11 healthy adults who were bilingual in English and Spanish. The authors performed exactly the same procedures used routinely for presurgical receptive language mapping. In each bilingual individual, the receptive language—specific map always encompassed the posterior portion of the superior temporal gyrus. In every case, however, substantial differences in the receptive language maps were also observed for the two languages, regardless of whether each participant's first language was English or Spanish.

Conclusions. Although the reasons for such differences and their ultimate significance in identifying the cerebral mechanisms of language are subject to continuing investigation, their presence is noteworthy and has practical implications for the surgical management of patients with lesions in the temporal and parietal regions of the dominant hemisphere.

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Andrew C. Papanicolaou, Panagiotis G. Simos, Joshua I. Breier, George Zouridakis, L. James Willmore, James W. Wheless, Jules E. C. Constantinou, William W. Maggio, and William B. Gormley

Object. In this paper the authors introduce a novel use of magnetoencephalography (MEG) for noninvasive mapping of language-specific cortex in individual patients and in healthy volunteers.

Methods. The authors describe a series of six experiments in which normative MEG data were collected and the reliability, validity, and topographical accuracy of the data were assessed in patients who had also undergone the Wada procedure or language mapping through intraoperative cortical stimulation.

Conclusions. Findings include: 1) receptive language—specific areas can be reliably activated by simple language tasks and this activation can be readily recorded in short MEG sessions; 2) MEG-derived maps of each individual are reliable because they remain stable over time and are independent of whether auditory or visual stimuli are used to activate the brain; and 3) these maps are also valid because they concur with results of the Wada procedure in assessing hemispheric dominance for language and with the results of cortical stimulation in identifying the precise topography of receptive language regions within the dominant hemisphere.

Although the MEG mapping technique should be further refined, it has been shown to be efficacious by correctly identifying the language-dominant hemisphere and specific language-related regions within this hemisphere. Further development of the technique may render it a valuable adjunct for routine presurgical planning in many patients who harbor tumors or have epilepsy.

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Andrew C. Papanicolaou, Panagiotis G. Simos, Joshua I. Breier, George Zouridakis, L. James Willmore, James W. Wheless, Jules E. C. Constantinou, William W. Maggio, and William B. Gormley

Object

In this paper the authors introduce a novel use of magnetoencephalography (MEG) for noninvasive mapping of language-specific cortex in individual patients and in healthy volunteers.

Methods

The authors describe a series of six experiments in which normative MEG data were collected and the reliability, validity, and topographical accuracy of the data were assessed in patients who had also undergone the Wada procedure or language mapping through intraoperative cortical stimulation.

Conclusions

Findings include: 1) receptive language-specific areas can be reliably activated by simple language tasks and this activation can be readily recorded in short MEG sessions; 2) MEG-derived maps of each individual are reliable because they remain stable over time and are independent of whether auditory or visual stimuli are used to activate the brain; and 3) these maps are also valid because they concur with results of the Wada procedure in assessing hemispheric dominance for language and with the results of cortical stimulation in identifying the precise topography of receptive language regions within the dominant hemisphere.

Although the MEG mapping technique should be further refined, it has been shown to be efficacious by correctly identifying the language-dominant hemisphere and specific language-related regions within this hemisphere. Further development of the technique may render it a valuable adjunct for routine presurgical planning in many patients who harbor tumors or have epilepsy.

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Hideaki Ishibashi, Panagiotis G. Simos, Eduardo M. Castillo, William W. Maggio, James W. Wheless, Howard L. Kim, Vijay Venkataraman, Daniel K. Sanders, Joshua I. Breier, Wenbo Zhang, Robert N. Davis, and Andrew C. Papanicolaou

Object. Magnetoencephalography (MEG) is a novel noninvasive diagnostic tool used to determine preoperatively the location of the epileptogenic zone in patients with epilepsy. The presence of focal slowing of activity recorded by electroencephalography (EEG) is an additional indicator of an underlying pathological condition in cases of intractable mesial temporal lobe epilepsy (MTLE). In the present study the authors examined the significance of focal, slow-wave and interictal spike activity detected using MEG in 29 patients who suffered from MTLE that was not associated with structural brain lesions.

Methods. All patients underwent resective surgery after MEG and EEG monitoring. Equivalent single-dipole modeling was applied to focal low-frequency magnetic activity (LFMA) and interictal paroxysmal activity. Lateralized LFMA was defined as trains of rhythmic activity over the temporal area, with frequencies lower than 7 Hz, which were easily distinguished from background activity.

Lateralized LFMA was found in 17 patients (58.6%); it always occurred on the side ipsilateral to the side of resection and displayed a maximum amplitude over the temporal area. Dipolar sources of magnetic flux computed during slow-wave trains were found in the majority of cases in the posterior superior temporal region and, occasionally, in mesial temporal structures that were subsequently resected. With respect to lateralization there was never disagreement between LFMA and MEG interictal spike sources. Thus, in patients with MTLE that is not associated with a mass lesion LFMA is topographically related to the epileptogenic area and, therefore, has value for reliable determination of the side and, possibly, the location of this area.

Conclusions. Although focal slowing of EEG background activity is generally considered to be a nonspecific sign of functional disturbance, interictal LFMA in patients with MTLE should be conceptualized as a distinct electrographic phenomenon that is directly related to the epileptogenic abnormality. Analyzing the interictal MEG distribution of LFMA and sharp activity improves the diagnostic utility of MEG in patients with suspected TLE who are undergoing surgical evaluation.