Biomedical subjects

Anil Nanda

Publications and source records attributed to Anil Nanda.

At least 19 recordsLinked to original sources

PubMed2006

Neurosurgical treatment of multiple sclerosis.

OBJECTIVES: To describe the role of neurosurgical techniques in treatment of symptoms of multiple sclerosis (MS). METHODS: A review of the existing world literature searching (using PubMed, August 22, 2005) for key words 'multiple sclerosis' and multiple symptoms associated with MS including trigeminal neuralgia, pain (pump and rhizotomy), spasticity, intrathecal pump, hydrocephalus and stimulation (brain and spinal). RESULTS: In total, 1,404 articles met selection criteria. These were narrowed based upon uniqueness of technique described, nature of information provided and avoidance of redundancy. Further, the methods listed were classified into groups of cranial and spinal techniques. Indications, brief description of technique and outcome/side effects were noted for each technique. DISCUSSION: A vast, growing body of literature exists for various neurosurgical applications for MS treatment. Older techniques such as rhizolysis for neuralgia and rhizotomy for spasticity have been modified using stereotactic radiosurgery and deep brain stimulation, along with central nervous system stimulation and intrathecal pumps. Other applications continue to be found with varying degrees of success. CONCLUSIONS: Neurosurgical techniques, based upon proper selection criteria, can significantly improve MS-related symptoms with low procedure-associated risk and therefore can substantially improve patients' quality of life.

Deep Brain Stimulation↗

PubMed2006

Spinal cord compression in a patient with a pain pump for failed back syndrome: a chalk-like precipitate mimicking a spinal cord neoplasm: case report.

OBJECTIVE AND IMPORTANCE: The use of intrathecal morphine has been effective with few complications for chronic intractable pain of both benign and malignant origins. A rare but serious problem that exists is the formation of an inflammatory mass at the catheter tip of the pain pump. CLINICAL PRESENTATION: We report the case of a 67-year-old female patient with failed back syndrome who presented with sensory complaints and back pain. INTERVENTION: Magnetic resonance imaging revealed impingement on the thoracic cord by a mass. The mass was originally thought to be a spinal cord tumor; however, operation and chemical analysis of the mass showed that it was a bupivacaine precipitate at the tip of the catheter of the pain pump. CONCLUSION: This is the first such case, to our knowledge, of a bupivacaine precipitate mimicking a spinal cord tumor.

Aged↗

PubMed2006

Augmentation of anterior lumbar interbody fusion with anterior pedicle screw fixation: demonstration of novel constructs and evaluation of biomechanical stability in cadaveric specimens.

OBJECTIVE: Anterior lumbar interbody fusion (ALIF) has proven effective for indications including discogenic back pain, nonunion, and instability. Current practice involves posterior pedicle screw augmentation of the ALIF procedure (ALIF-PPS). This approach requires intraoperative repositioning of the patient for percutaneous posterior pedicle screw placement. We have developed a novel technique in which the ALIF procedure is augmented with anterior pedicle screws (APS; ALIF-APS). In this study, we introduce this new technique and compare the biomechanical stability of the novel ALIF-APS with the current standard ALIF-PPS. METHODS: The technique was demonstrated in a cadaveric L4-S1 specimen using neuronavigation and fluoroscopy. Plain radiographs and computed tomographic scans of the construct were obtained. Twelve cadaveric spines (7 men and 5 women) from donors with an average age of 81 years (range, 64-93 yr) were then harvested from L4-S1. Six specimens were dedicated to ALIF-APS constructs, and the remaining six were dedicated to ALIF-PPS constructs. The specimens were then studied at L5-S1 in the following steps: 1) intact form, 2) after anterior discectomy, 3) after implantation of titanium cages (ALIF), and 4) after APS or PPS fixation in conjunction with the ALIF. Measurements were obtained in axial rotation and left and right lateral bending flexion-extension. Data were normalized by calculating the ratio of the stiffness of the instrumented to the intact spine. Statistical analyses were then performed on the data. RESULTS: Radiographs and computed tomographic scans of the construct showed accurate placement of the APS at L5 and S1. The normalized data showed that ALIF-APS and ALIF-PPS had approximately equal stability in axial rotation (1.17 +/- 0.43 versus 0.85 +/- 0.14), lateral bending (0.93 +/- 0.22 versus 0.95 +/- 0.16), and flexion- extension (0.77 +/- 0.13 versus 0.84 +/- 0.2). Paired t test analysis did not show a significant difference between the biomechanical stiffness of ALIF-APS and ALIF-PPS in axial rotation, lateral bending, and flexion-extension. CONCLUSION: We demonstrate a new technique in a cadaveric specimen whereby the ALIF procedure is augmented with APS fixation using neuronavigation and fluoroscopy. Biomechanical evaluation of the constructs suggests that the ALIF-APS has comparable stability with ALIF-PPS. APS augmentation of ALIF has potential advantages over the current standard ALIF-PPS because it can 1) eliminate the patient repositioning step, 2) minimize the total number of incisions and the total operative time, and 3) protect against dislocation of the ALIF interbody graft or cage. Work is in progress to develop a low-profile system for the novel APS constructs described here.

Aged↗

PubMed2006

Cerebral ischemia as a presenting feature of intracranial aneurysms: a negative prognostic indicator in the management of aneurysms.

OBJECTIVE: Cerebral ischemia (stroke) can be a presenting clinical feature of intracranial aneurysms and may herald poor prognosis. METHODS: A retrospective review of admissions for aneurysms over a 6-year period revealed that 12 patients (5%) had stroke or stroke-like presentations among 236 patients with intracranial aneurysms. Patient demographics, characteristics of aneurysms, and management were analyzed. RESULTS: Of 12 patients reviewed, nine had anterior circulation aneurysms. Two patients presented with subarachnoid hemorrhage and 10 with unruptured aneurysms. Eleven patients had stroke at the time of presentation, and five had a previous history of transient ischemic attacks. Ten patients had hypertension and eight were active smokers. The mean size of 10 aneurysms was 11.8 mm. Surgical extirpation of the aneurysms was performed in all cases. Four cases revealed thrombus in the aneurysm and one was atherosclerotic. The 6-month outcome was good in seven patients (58%) and fair in four patients (33%). One patient died. This outcome was significantly worse (P < 0.01) compared to that of good grade aneurysms in our database. Hypertension was a significant indicator of poor outcome (P < 0.02). CONCLUSION: Ischemic episodes as a presenting feature of intracranial aneurysms could be indicators of poor prognosis. Routine evaluation of stroke patients for aneurysms may help in early diagnosis. In addition, surgical obliteration of aneurysms could prevent subsequent strokes and neurological deficits.

Adult↗

PubMed2006

Accuracy of pedicle screw placement for lumbar fusion using anatomic landmarks versus open laminectomy: a comparison of two surgical techniques in cadaveric specimens.

OBJECTIVE: We determined whether the accuracy of lumbar pedicle screw placement is optimized by performing a laminectomy before screw placement with screw entry point and trajectory being guided by pedicle visualization and palpation (Technique 1). This technique was compared with a technique using anatomic landmarks for pedicle screw placement (Technique 2). The biomechanical stability of the instrumented constructs, in the absence and presence of a laminectomy, was also compared. METHODS: Twelve L1-L3 specimens were harvested from fresh cadavers. The intact laminectomy and instrumented spines were biomechanically tested in flexion and extension, lateral bending, and axial rotation. Laminectomies were performed in six of the 12 specimens before pedicle screw placement using Technique 1. The remaining six specimens underwent pedicle screw and rod fixation using Technique 2. Computed tomographic images were obtained for all instrumented specimens. Deviation of the screws from the ideal entry point or trajectory was analyzed to quantitatively compare the two techniques. RESULTS: Computed tomographic analysis of the specimens showed that all screw placements were within the pedicles. Scatter plot analysis demonstrated that screws placed using Technique 2 were more likely to have the combination of entry points and trajectories medial to the ideal entry point and trajectory. Laminectomy did not weaken the final pedicle screw and rod-fixated constructs. CONCLUSION: All screw placements were grossly within the confines of the pedicles, regardless of technique, as evidenced by computed tomographic analysis. Furthermore, the anatomic landmark technique and the open laminectomy technique yielded biomechanically equivalent pedicle screw and rod-fixated constructs.

Aged↗

PubMed2006

Retrosigmoid intradural suprameatal approach: advantages and disadvantages from an anatomical perspective.

OBJECTIVE: To assess the advantages and disadvantages of the retrosigmoid intradural suprameatal approach by studying the microsurgical anatomy. This study was performed primarily to assess the advantages of the retrosigmoid intradural suprameatal approach by measuring the amount of increased exposure it provides for lesions of the cerebellopontine and petroclival region as well as to identify the disadvantages of the approach. METHODS: Twenty sides of 10 cadaver heads (embalmed and injected) were dissected under x3 to x40 magnification. A standard retrosigmoid craniotomy was made. The cerebellopontine cistern was entered to expose the neurovascular structures, and the internal auditory canal was opened by drilling the margin of the internal auditory meatus. After this, the suprameatal tubercle was drilled, followed by additional drilling to resect the petrous apex. The trigeminal root was mobilized completely after opening Meckel's cave. During drilling, care was taken to preserve the posterior and superior semicircular canals, petrosal sinus, and the internal carotid artery. RESULTS: The approach enhanced the exposure of the cerebellopontine cistern and Meckel's cave. There was an additional exposure of 10.7 +/- 1.16 mm length of trigeminal nerve on the right side and an additional 10.7 +/- 1.25 mm on the left. This helped to mobilize and further retract the trigeminal root. Although it facilitated the view of the neurovascular structures medial to the internal acoustic meatus, the depth of exposure did not vary much from a traditional retrosigmoid approach nor did it increase the angle of exposure or the visualization of the clivus and more medially located structures. CONCLUSION: This approach is suitable for lesions mainly in the posterior fossa with some extension into the middle fossa in the anterolateral direction. The key benefits of this approach are the length of trigeminal nerve exposure and the subsequent mobilization that improves visualization of the structures medial to the internal auditory canal, to the petrous apex, Meckel's cave, and the posterior end of the cavernous sinus.

Brain Stem↗

PubMed2006

Internal jugular venous thrombosis as a complication after an elective anterior cervical discectomy: case report.

OBJECTIVE: Anterior cervical discectomy is one of the most common spine procedures in neurosurgery. Various complications, including hoarseness, hematoma, and dysphagia, have been reported in the literature. We report the first case of internal jugular venous thrombosis after an elective anterior cervical discectomy. CLINICAL PRESENTATION: A 35-year-old woman with past medical history significant only for hypercholesterolemia and cholecystectomy underwent an anterior cervical discectomy with fusion for a symptomatic cervical disc at the C5-C6 level. Intraoperatively, the patient had venous bleeding, which was adequately controlled. The procedure was completed with good hemostasis before closure. The patient was discharged home 1 day after the surgery. She was readmitted 5 days later with a 2-day history of a swollen right neck. The patient had no respiratory symptoms, but did report mild dysphagia. A hematoma was suspected. INTERVENTION: A computed tomographic scan of the neck was performed when the patient presented with cervical swelling. This was suggestive of a right internal jugular venous thrombosis. This diagnosis was confirmed with cervical ultrasound. The patient was seen by the vascular surgery department. The hospital course was otherwise uneventful and the patient was discharged 3 days later on oral anticoagulation with warfarin. CONCLUSION: This is the first report of internal jugular venous thrombosis after an elective anterior cervical discectomy. Internal jugular venous thrombosis should be considered in the differential diagnosis of a patient presenting with cervical swelling after an anterior cervical discectomy.

Adult↗

PubMed2006

Predictive factors for dural tear and cerebrospinal fluid leakage in patients undergoing lumbar surgery.

OBJECT: A dural tear resulting in a cerebrospinal fluid (CSF) leak is a well-known risk of lumbar spinal procedures. The authors hypothesized that the incidence of CSF leakage is higher in cases involving repeated operations and those in which the surgeon performing the surgery is less experienced; however, they postulated that the overall outcome of the patient would not be adversely affected by a dural tear. METHODS: An institutional review board-approved protocol at Louisiana State University Health Sciences Center, Shreveport, was initiated in August 2003 to allow prospective comparison of data obtained in patients in whom a CSF leak occurred (Group A) and those in whom no CSF leak occurred (Group B) during lumbar surgery. Basic demographic information, descriptive findings regarding the tear, history of other surgeries, hospital length of stay (LOS), and immediate disposition at the time of discharge were compared between the two groups. Seventy-seven patients were eligible for this study. One patient refused to participate. In 12 (15.8%) of 76 patients CSF leakage developed. In three patients the presence of a tear was questioned, and the patients were clinically treated as if a tear were present. The patients in Group A were older than those in Group B (59.8 +/- 16.9 and 49.4 +/- 13.6 years of age, respectively; p = 0.02, Fisher exact test). In terms of those with a history of surgery, there was no significant difference between patients with and patients without a CSF leak (three [25%] of 12 patients [Group A] compared with 28 [43.8%] of 64 patients [Group B]; p = 0.34, two-sample t-test). In the 12 patients with dural tears, nine (75%) were caused by a resident-in-training, and the Kerrison punch was the instrument most often being used at the time (55%). This is significantly greater than 50% at the 5% level (p = 0.044, binomial test). The authors were able to repair the tear primarily with suture in all but one patient, whose tear was along the nerve root sleeve. In all cases fibrin glue and a muscle/fat graft were used to cover the tear, and all patients were assigned to bed rest from 24 to 48 hours after the operation. In Group A one patient required rehabilitation at discharge. The LOS in Group A was greater than that in Group B (median 5 days compared with 3 days), but no additional complication was noted. CONCLUSIONS: The incidence of CSF leakage was 16% in 76 patients, and there were no other complications. Older patient age and higher level of the surgeon's training were factors contributing to the incidence, but the history of surgery was not.

Adult↗

PubMed2005

Technical note: preliminary results in development of a novel intracisternal penicillin seizure model in the rat.

In order to develop an intracisternal penicillin rat model of epilepsy, eleven anesthetized male Wistar rats were studied. 5 underwent intracisternal injection of penicillin (doses 150,000-300,000 units) in the prone position, and another 5 underwent intraperitoneal penicillin injection; one died following intracisternal injection, prior to further study. Time between penicillin injection and seizure induction (determined by electroencephalography) was recorded. Each animal had a tracheostomy, and was mechanically ventilated and carefully monitored for adverse effects. Seizures were noted in an average of 13:42 minutes following penicillin injection (range 4:30-23:20) for the intracisternally (IC) injected group. Both episodic and continuous seizure activity was seen, and a dose-dependent effect was seen (quicker-onset, more continuous seizures with higher doses, in the IC group). Onset was significantly faster in the IC than for the intraperitoneally injected group (all >1 hour for the latter group in our study). 96 total separate seizure episodes were seen, ranging from 3 to 540 seconds. Epileptic activity could be seen in all IC-injected rats lasting over 1 hour into the study. The intracisternal penicillin injection rat model appears to provide a quick-onset, reliable method of inducing seizure activity in the rat model while leaving the cranial vault intact.

Animals↗

PubMed2005

Electroconvulsive therapy for seizure control: preliminary data in a new seizure generation and control model.

Electroconvulsive therapy (ECT) effect upon seizure cessation was studied in five male Wistar rats using a penicillin intracisternal injection model (which did not damage the cranial vault). Animals were observed both clinically and electrographically for seizure development. ECT was applied at varying times following onset of seizure, at varying parameters (frequency, pulsewidth, and duration). ECT affected EEG seizure pattern in several different stimulation parameter-dependent ways: (1) modulation to different pattern; (2) increased interictal time; and (3) seizure cessation. Stimulation with higher, sustained current (50 mA) led to changes in seizure amplitude; stimulation at pulses of current led to seizure frequency dimunition, and at certain characteristic pulses "capture" was seen as the EEG activity mimicked the ECT-inducing stimulation pattern. Interictal time was usually increased by sustained, continuous (rather than pulsatile) stimulation. Seizure activity was completely stopped in several instances using parameters of 800 pulses at a frequency of 200 Hz, with 2.56 ms pulsewidth and 50 mA of current (in consecutive iterations for one specimen). No ECT-related adverse effects were noted. Analogous to the heart, pacing or defibrillating the brain using external scalp electrodes may have a role in the control of otherwise intractable seizures.

Age of Onset↗

PubMed2005

Concomitant choroid plexus papillomas involving the third and fourth ventricles: A case report and review of the literature.

Choroid plexus papillomas (CPP) are histopathologically benign and rare central nervous system (CNS) neoplasms arising from the epithelium of the choroid plexus. The most common site of presentation of these lesions is in the fourth ventricle in adults and lateral ventricles in children. Third ventricular CPP are uncommon. In this study, we present a case of a 66-year-old woman with complaints of progressive confusion, lethargy, and weakness who was found to have concomitant third and fourth ventricular masses on imaging studies. The patient underwent a biopsy of the third ventricular mass. The biopsy was followed by staged resections of the fourth and third ventricular masses, respectively. Pathology from the biopsy and both resections was benign CPP. Multifocal concomitant CPP is rare. Concomitant CPPs may be secondary to mere coincidental tumor occurrence or to biologic seeding of cerebrospinal fluid (CSF) from a primary CPP despite otherwise benign histopathology. The primary treatment for CPP is surgical resection. Post-operative chemotherapy or radiation for CPP is of controversial benefit.

Aged↗

PubMed2005

Assessment of pain control, quality of life, and predictors of success after gamma knife surgery for the treatment of trigeminal neuralgia.

OBJECT: There are various surgical treatment alternatives for trigeminal neuralgia (TN), but there is no single scale that can be used uniformly to assess and compare one type of intervention with the others. In this study the objectives were to determine factors associated with pain control, pain-free survival, residual pain, and recurrence after gamma knife surgery (GKS) treatment for TN, and to correlate the patients' self-reported quality of life (QOL) and satisfaction with the aforementioned factors. METHODS: Between the years 2000 and 2004, the authors treated 81 patients with medically refractory TN by using GKS. Fifty-two patients responded to a questionnaire regarding pain control, activities of daily living, QOL, and patient satisfaction. The median follow-up duration was 16.5 months. Twenty-two patients (42.3%) had complete pain relief, 14 (26.9%) had partial but satisfactory pain relief, and in 16 patients (30.8%) the treatment failed. Seven patients (13.5%) reported a recurrence during the follow-up period, and 25 (48.1%) reported a significant (> 50%) decrease in their pain within the 1st month posttreatment. The mean decrease in the total dose of pain medication was 75%. Patients' self-reported QOL scores improved 90% and the overall patient satisfaction score was 80%. CONCLUSIONS: The authors found that GKS is a minimally invasive and effective procedure that yields a favorable outcome for patients with recurrent or refractory TN. It may also be offered as a first-line surgical modality for any patients with TN who are unsuited or unwilling to undergo microvascular decompression.

Adult↗

PubMed2005

CD40/CD40 ligand signaling in mouse cerebral microvasculature after focal ischemia/reperfusion.

BACKGROUND: CD40/CD40 ligand (CD40L) signaling contributes to proinflammatory and prothrombogenic responses in the vasculature. CD40/CD40L expression is elevated in patients after a transient ischemic attack or stroke. The purpose of this study was to investigate the role of CD40/CD40L signaling in cerebral microvascular dysfunction and tissue injury response to middle cerebral artery occlusion (MCAO) and reperfusion. METHODS AND RESULTS: Intravital fluorescence microscopy was used to visualize the cerebral microcirculation of wild-type (WT), CD40-deficient, and CD40L-deficient mice subjected to 1-hour MCAO and 4-hour reperfusion. The adhesion of platelets and of leukocytes and vascular permeability were measured in postcapillary venules after 4-hour and 1-hour reperfusions, respectively. Cerebral infarct volume was analyzed 24 hours after reperfusion. Platelet and leukocyte adhesion was elevated and blood/brain barrier function was compromised by MCAO in WT mice. Blood cell recruitment and increased permeability were blunted in both CD40-deficient and CD40L-deficient mice. Infarct volume was also reduced in CD40- and CD40L-deficient mice compared with WT mice. CONCLUSIONS: Our findings indicate that CD40/CD40L signaling contributes to inflammatory and prothrombogenic responses and brain infarction induced by MCAO and reperfusion. The CD40/CD40L dyad may play a significant pathogenic role in the acute phase of ischemic stroke.

Animals↗

PubMed2005

Intracranial fungal granuloma: analysis of 40 patients and review of the literature.

OBJECTIVE: To describe the characteristics of patients diagnosed with intracranial fungal granuloma (IFG) in the largest reported series to date (to our knowledge). METHODS: A 22-year retrospective, multi-institutional review of 40 patients, aged 16 to 62 years (mean, 40.2 years), was performed in patients with histopathologically confirmed IFG. The variables were symptoms/signs at presentation, predisposing factors, location of granuloma, involvement of paranasal sinuses, diagnostic studies including blood and urine cultures, surgical procedures performed, specific organism identified, treatment, and prognosis. Plain x-rays, computed tomography, and/or magnetic resonance imaging scans were performed. RESULTS: Predominant symptoms included headache (83%), vomiting (65%), proptosis (48%), and visual disturbances (48%). Other symptoms were fever, nasal congestion, and seizures (7 [18%]). Common signs included papilledema (12 [30%]), with cranial neuropathy (I, III/IV/VI, and V in 4, 7, and 2 patients, respectively), hemiparesis (3), and meningismus (3). Predisposing factors were diabetes (16 [40%]), tuberculosis (7 [18%]), and immunocompromise related to renal transplant (2), non-Hodgkin's lymphoma (1), and human immunodeficiency virus (1). Location was primarily frontal (10 [25%]), with anterior cranial fossa involved in 8 (20%) patients; 6 (15%) patients had sellar/parasellar involvement. Eighteen (40%) had paranasal sinus involvement. Twenty-nine patients underwent craniotomy for resection, with 11 undergoing biopsy (of which 3 were transsphenoidally approached). Histopathology revealed aspergilloma (25 [63%]), mucormycosis (7 [18%]), cryptococcoma (3), cladosporidium (3), Bipolaris hawaiiensis (1), and Candida species(1). Microbiological analysis of the specimen was positive in 28 (60%) patients. All patients were treated with amphotericin B, fluconazole, and/or flucytosine. Only 26 patients completed amphotericin B therapy (due to nephrotoxicity). Mortality was 63%, most commonly due to meningoencephalitis (16 [36%]). CONCLUSIONS: High index of suspicion of IFG should exist for the following groups: (1) immunocompromised patients with intracranial lesions and (2) diabetic patients with intracranial and rhinocerebral mass lesions. Early diagnosis, surgical decompression, and a complete course of promptly initiated antifungal therapy are associated with better prognosis.

Adolescent↗

PubMed2005

Factors influencing outcome in intracerebral hematoma: a simple, reliable, and accurate method to grade intracerebral hemorrhage.

BACKGROUND: Intracerebral hemorrhage (ICH) is a major public health problem. This subset of stroke often coexists with other serious medical problems such as hypertension, diabetes, and obesity. Management of hemorrhagic stroke is controversial and there is no standardized system for assessing presentation and predicting outcome of this disease. We propose a new grading system based on clinical and radiologic factors important in influencing outcome in ICH that can be used by the entire health care team. METHODS: We conducted a retrospective study of the last 50 patients who presented with hypertensive ICHs to Louisiana State University Health Sciences Center in Shreveport during 2001 to 2003. Significant predictors of outcome at 6 months as measured by the Glasgow outcome score (GOS) were determined and a grading system based on clot volume, hydrocephalus on initial computed tomographic scan, and focal neurologic deficit was formulated. RESULTS: Three factors observed to have significant association with GOS were presence of a focal neurologic deficit on initial presentation (P = .003), presence of hydrocephalus on initial computed tomographic scan (P < .0001), and clot volume (P = .003). Patients were scored on these variables as follows: neurologically intact (0 point), any focal neurological deficit (1 point); absence of hydrocephalus (0 point), presence of hydrocephalus (1 point); and clot volume less than 20 mL (1 point), 20 to 50 mL (2 points), and greater than 50 mL (3 points) [corrected] The scores were summed to assign an ICH grade to each patient for predicting his GOS at 6 months. Given the nonsignificant difference between a patient's grade and his actual observed GOS (mean difference 0.04, P = .79), as well as their significant correlation (correlation coefficient = 0.76, P < .0001), we believe our grading system is useful for predicting a patient's GOS. CONCLUSION: An accurate and reliable grading scale for ICH is helpful in standardizing the management of ICH, improving communication of patient presentation among health care workers, and predicting outcomes.

Adult↗

PubMed2005

Control of refractory status epilepticus precipitated by anticonvulsant withdrawal using left vagal nerve stimulation: a case report.

OBJECTIVE: To describe a case of left vagal nerve stimulation (VNS) resulting in immediate cessation of status epilepticus (SE) with good neurological outcome. CASE DESCRIPTION: A 30-year-old man with medically intractable seizures including episodes of SE was successfully treated using left VNS. After requiring discontinuation of phenytoin, valproic acid, carbamazepine, and topiramate because of severe allergic reactions resembling Stevens-Johnson syndrome, the patient required pentobarbital coma along with phenobarbital, tiagabine, and levetiracetam for seizure frequency reduction. He underwent left vagal nerve stimulator placement after nearly 9 days of barbiturate-induced coma, with stimulation initiated in the operating room. On the following day, electroencephalography revealed resolution of previously observed periodic lateral epileptiform discharges and the patient was free of seizures. Prestimulation seizure frequency was recorded at 59 times a day, with some seizures enduring 45 minutes despite barbiturate coma. Poststimulation, the patient has been free of seizures for 19 days and is presently taking only levetiracetam and phenobarbital, from which he continues to be successfully weaned without seizures. He is awake, alert, and can recall events leading up to his seizures, with good long-term memory and residual left upper extremity and lower extremity weakness. CONCLUSION: This case illustrates the role of left vagal stimulation in the treatment of SE and otherwise medically intractable seizures caused by allergic reactions. To our knowledge, this is the first case in the world literature for adults reporting cessation of SE after VNS. Another case with a similar improvement has been reported in the pediatric population.

Adult↗

PubMed2005

Primary central nervous system lymphoma of the brain stem responding favorably to radiosurgery: a case report and literature review.

OBJECTIVE: To explore various therapeutic alternatives and evaluate the clinical results of patients with primary central nervous system lymphoma (PCNSL). We report a case of PCNSL with involvement of the brain stem managed with radiosurgery using the Leksell gamma knife as the treatment modality. CASE DESCRIPTION: A 55-year-old white woman presented with complaints of weakness on the left side of her body and double vision associated with a frontal headache. Nervous system examination revealed right-sided oculomotor palsy and left-sided motor paresis, grade 2/5, in both upper and lower limbs. Her Karnofsky performance score was 50. A contrast-enhanced magnetic resonance imaging scan of the brain revealed an irregular space-occupying lesion in the pons that enhanced uniformly with gadolinium. A frame-based stereotactic biopsy was performed revealing a B-cell malignant lymphoma. Subsequently, stereotactic radiosurgery using the Leksell gamma knife was performed. A dose of 11 Gy was delivered to the tumor margin. A follow-up magnetic resonance imaging scan after 2 months revealed a 50% reduction in the size of the enhancing lesion. CONCLUSION: Our own results and limited evidence from the literature suggest stereotactic radiosurgery as a potentially safe and effective treatment option in patients with PCNSL.

Brain Stem Neoplasms↗

PubMed2005

Role of stereotactic radiosurgery as a primary treatment option in the management of newly diagnosed multiple (3-6) intracranial metastases.

OBJECTIVE: The objective of this study was to assess the role of stereotactic radiosurgery in the management of newly diagnosed multiple intracranial metastases from known primary cancer locations. METHODS: Fifty (29 women and 21 men) patients received radiosurgery for newly diagnosed 3 or more metastatic brain tumors. Their mean age was 53 years. Lung cancer was the most common primary cancer (66%). RESULTS: Arrest in the growth of irradiated tumors was achieved in 41 (82%) patients. Eight patients (16%) required further intervention for tumors in other brain locations. Mean survival after diagnosis of brain disease was 12 months and the brain disease-controlled period was 19 months. The period of brain disease control prolonged (P=.03) with decreasing tumor volumes (<10 mL). Control of treated tumors positively affected survival after diagnosis of brain disease (P=.0001). CONCLUSION: Radiosurgery as an adjuvant improves survival in patients with cancer who have newly diagnosed multiple intracranial metastases by arresting the growth of tumors.

Adult↗