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Journal: World neurosurgery

142

Complete brachial plexus avulsion injury is a severe disabling injury due to traction to the brachial plexus. Brachial plexus re-implantation is an emerging surgical technique for the management of complete brachial plexus avulsion injury.

Concepts: Surgery, Injuries, Injury, Amputation, Brachial plexus, Avulsion injury, Avulsion, Brachial plexus injury

36

More prehistoric trepanned crania have been found in Peru than any other location worldwide. We examine trepanation practices and outcomes in Peru over nearly 2000 years from 400 BC to provide a perspective on the procedure with comparison to procedures/outcomes of other ancient, medieval and American-Civil-War cranial surgery. . Data on trepanation demographics, techniques, and survival rates were collected through the scientific analysis of more than 800 trepanned crania discovered in Peru, through field studies and the courtesy of museums and private collections in the U.S. and Peru, over nearly 3 decades. Data on procedures and outcomes of cranial surgery ancient, medieval and during 19th-century through the American-Civil-war were obtained via a literature review. Successful trepanations from prehistoric times through the American Civil War likely involved shallow surgeries that did not pierce the dura mater. While there are regional and temporal variations in ancient Peru, overall long-term survival rates for the study series were about 40% in the earliest period (400-200 BC), with improvement to a high of 91% in samples from AD 1000-1400, to an average of 75-83% during the Inca Period (AD 1400s-1500). In comparison,the average cranial surgery mortality rate during the American Civil war was 46-56%, and short and long-term survival rates are unknown. The contrast in outcomes highlights the astonishing success of ancient cranial surgery in Peru in the treatment of living patients.

Concepts: Time, United States, Al-Andalus, American Civil War, Civil war, Inca Empire, Inca, Franklin Pierce

28

OBJECTIVE: Ventriculoperitoneal (VP) shunt surgery is the predominant mode of therapy for patients with hydrocephalus. However, it has potential complications that may require multiple surgical procedures during a patient’s lifetime. The objective of this study is to review our long-term experience and evaluate the risk factors for VP shunt failure after initial shunt surgery and after subsequent revisions. METHODS: Patients who underwent VP shunt surgery for hydrocephalus were included. Medical charts, operative reports, imaging studies, and clinical follow-up evaluations were reviewed and analyzed retrospectively. RESULTS: A total of 1015 patients with the median age of 41.6 (range, 0 - 90.3) years at the time of VP shunt surgery were included. The mean and median follow up was 9.2 and 6.5 years, respectively. Adult patients (≥ 17 years) accounted for 70.0% of the patients. The overall shunt failure rate requiring shunt revision(s) was 46.3% and the majority of shunt revisions occurred during the first 6 months after shunt placement. The shunt revision rate was significantly higher in pediatric (< 17 years) than in adult (> 17 years) patients (78.2% vs.32.5%, P < 0.001). Age at the time of shunt surgery, prior treatments to shunt surgery, etiology of hydrocephalus, and hydrocephalus type were independently associated with the incidence of shunt revision. Age at shunt placement and gender were significantly associated with multiple shunt revisions. Among population with at least one shunt revision, pediatric patients had significantly lower shunt survival rate and shorter median time to subsequent shunt revision than the adult (> 17 years) patients; male patients had higher odds for multiple revisions than females. CONCLUSION: The findings of the study indicate that age at shunt placement, etiology of hydrocephalus, type of hydrocephalus, and prior treatments before shunt surgery were independently significantly associated with the shunt survival. Prospective controlled studies are required to address the observed associations between the risk factors and incidence of shunt revisions in these patients.

Concepts: Time, Medicine, Surgery, Median, Physician, Arithmetic mean, Hydrocephalus, Cerebral shunt

28

OBJECTIVE: Endoscopy has provided a less invasive approach to skull base surgery, mainly through endonasal routes, but has been limited in its applications due to potential complications. The aims of this study were to evaluate the feasibility of the purely endoscopic extradural transcranial approach to lateral and central skull base through asubtemporal keyhole, and to better understand potential distortions of the related anatomy via endoscopy. METHODS: Ten fresh cadaver heads were studied with 4-mm 0- and 30-degree endoscopes to develop the surgical approach and to identify surgical landmarks. RESULTS: The endoscopic extradural subtemporal approach was divided into three sections after exposure of the extradural space in the middle cranial fossa: 1) exposure of the lateral wall of the cavernous sinus and the preauricular infratemporal fossa; 2) anterior petrosectomy and posterior cranial fossa exploration; and 3) unroofing of the tympanic cavity and exposure of the facial nerve. This keyhole endoscopic technique clearly visualized anatomical landmarks of the lateral and central skull base via an extradural subtemporal route. CONCLUSION: The endoscopic extradural subtemporal approach was feasible. This approach could display a wide range of lateral and central skull base structures with minimal invasiveness. The use of extradural space would be key to performing safe and effective endoscopic skull base surgery.

Concepts: Endoscopy

28

OBJECTIVE: Gonadotroph pituitary adenomas are common, but the overwhelming majority are classified as non-functioning adenomas. Approximately one-third secrete follicle-stimulating hormone (FSH) and/or luteinizing hormone (LH), resulting in an increase in serum levels; however, the sex hormone levels are typically not elevated and the secreted gonadotropin hormones are thought to be biologically inactive. Rarely, gonadotroph adenomas induce an ovarian hyperstimulation syndrome in females. In males, an increase in testosterone level is even more rare. The authors report the case of a male patient with a gonadotroph pituitary adenoma causing hypersecretion of testosterone and review the medical literature. CASE REPORT: A 45-year-old man had progressive bilateral visual loss over a 4-year period. Bitemporal hemianopsia was diagnosed by an ophthalmologist, but no other symptoms were reported. Neurosurgical evaluation was otherwise normal. MRI of the brain showed a large enhancing sellar and suprasellar tumor consistent with pituitary macroadenoma. Levels of FSH, LH, α subunit, testosterone, free testosterone, and prolactin were elevated. The patient underwent transsphenoidal resection of the pituitary tumor. Pathological analysis confirmed the diagnosis of pituitary adenoma, and immunohistochemistry demonstrated a population of cells with cytoplasmic staining for FSH but not for LH. The postoperative hormonal profile showed normalization of FSH and low LH, testosterone, morning cortisol level, and free thyroxine. The patient was treated with levothyroxine and hydrocortisone therapy for replacement. His vision subjectively improved, with formal visual testing follow-up to monitor the degree of improvement. CONCLUSIONS: Gonadotroph adenomas are considered a type of non-functioning pituitary tumors, since the commonly associated increase in serum FSH and LH does not typically result in elevated sex hormone level. Herein, we report a rare case of high testosterone level caused by a gonadotroph adenoma successfully treated with transsphenoidal resection. Interestingly, in adult males the increase in sex hormones does not seem to lead to a recognizable clinical syndrome, and the clinical presentation remains similar to that of non-functioning adenomas.

Concepts: Pituitary adenoma, Hormone, Luteinizing hormone, Types of cancer, Testosterone, Neuroendocrinology, Follicle-stimulating hormone, Bitemporal hemianopsia

27

Cauda equina syndrome (CES) is a rare but important neurosurgical emergency. Despite being a recognised clinical entity since 1934, there remains significant uncertainty in the literature regarding the urgency for its surgical intervention. The past decade has seen the emergence of the much referred to 48-hour limit as a possible window of safety. The ramifications of this time-point are significant for early patients who may subsequently have urgent treatment delayed, and for litigation cases after which adverse decisions are more likely to occur.

Concepts: Hospital, Surgery, Cauda equina, Cauda equina syndrome, Limit superior and limit inferior

27

OBJECTIVE: To assess clinical outcomes in patients receiving Gamma Knife radiosurgery (GK) for treatment of brain metastases from melanoma and evaluate for potential predictive factors. METHODS: We reviewed 188 GK procedures in 129 consecutive patients that were treated for brain metastases from melanoma. The population consisted of 84 males and 45 females with a median age of 57 years. Fifty-five patients (43%) had a single metastasis. Seventy-one patients (55%) received chemotherapy, 58 patients (45%) received biologic agents, and 36 patients (28%) received prior whole brain radiation therapy (WBRT). The median marginal dose was 18.8 Gy (range 12-24 Gy). RESULTS: Actuarial survival was 52%, 26%, and 13% at 6, 12, and 24 months, respectively. The median survival time was 6.7 months. Local tumor control was 95%, 81% 53% at 6, 12, and 24 months, respectively. The median time to LBF was 25.2 months. Freedom from distant brain failure was 40%, 29%, and 10% at 6, 12, and 24 months, and the median time to DBF was 4.6 months. At the time of data analysis, 108 patients (84%) had died. Fifty-eight patients (52%) died from neurologic death. The median time to neurologic death from GK treatment was 7.9 months. Multivariate analysis revealed that hemorrhage of metastases prior to GK (p=0.02) and LBF (p=0.03) were the dominant predictors of neurologic death. CONCLUSIONS: GK achieves excellent local control and may improve outcomes as a component of a multidisciplinary treatment strategy. Distant brain failure and neurologic demise remain problematic and prospective trials are necessary.

Concepts: Cancer, Metastasis, Oncology, Chemotherapy, Median, Brain tumor, Melanoma, Gamma knife

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OBJECTIVE: to review the basic principles and techniques of transcranial magnetic stimulation and provide information and evidence regarding its applications in spinal cord injury clinical rehabilitation. METHODS: A review of the available current and historical literature regarding transcranial magnetic stimulation and a discussion of its potential use in spinal cord injury rehab was conducted. RESULTS: TMS provides reliable information about the functional integrity and conduction properties of the corticospinal tracts and motor control in the diagnostic and prognostic assessment of various neurological disorders. It allows one to follow the evolution of motor control and to evaluate the effects of different therapeutic procedures. MEPs can be useful in follow-up evaluation of motor function during treatment and rehabilitation, specifically in spinal cord injury and stroke patients. While studies regarding somatomotor functional recovery after spinal cord injury have shown promise, it will require further trials to provide strong and substantial evidence. CONCLUSIONS: TMS is a promising non-invasive tool for the treatment of spasticity, neuropathic pain and somatomotor deficit following SCI. Further investigation is needed to demonstrate whether different protocols and applications of stimulation, as well as alternative cortical sites of stimulation may induce more pronounced and beneficial clinical effects.

Concepts: Spinal cord, Evaluation, Neuropsychology, Transcranial magnetic stimulation, Motor skill, Primary motor cortex, Medulla oblongata, Corticospinal tract

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OBJECTIVE: Paleoneurosurgery represents a comparatively new developing direction of neurosurgery dealing with archaeological skull and spine finds and studying their neurosurgical aspects. Trepanation of the cranial vault was a widespread surgical procedure in antiquity and the most convincing evidence of the ancient origin of neurosurgery. The present study considers a case of trepanation from the Middle Bronze Age Greece (1900- 1600 B.C.). METHODS: The skull under study belongs to skeletal material unearthed from Kirra, Delphi (Central Greece). Macroscopic examination and palpation, as well as three-dimensional Computed Tomography were used in this study. RESULTS: There is osteological evidence that the skull belongs to a male individual that died 30-35 years old. The procedure of trepanation was performed on the right parietal bone. Both macroscopic and CT evaluation demonstrate an intravital bone reaction at the edges of the aperture. Projected on the right surface of the brain, the trepanation is located on the level of the central groove. The small dimensions and the symmetrical shape of this hole give us an indication that it was made by a metal tool. CONCLUSION: The authors conclude that this paleopathological case provides valuable information about the condition of life and the pre-hippocratic neurosurgical practice in Bronze Age Greece.

Concepts: Bone, Surgery, Skull, Slovakia, Neurosurgery, Tin, Ancient Egypt, Bronze Age

26

To analyze the safety and efficacy of neuroendoscopic colloid cyst resection and to examine patient satisfaction. This study presents retrospective analysis of a single surgeon’s experience with neuroendoscopic resection of colloid cysts.

Concepts: Cyst, Colloid cyst