Giant cell tumour of the skull base: MRI appearances. Case report.
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Adult↗
Biomedical subjects
D Uttley
Publications and source records attributed to D Uttley.
Gliomyosarcoma: an immunohistochemical analysis.
Tumours of mixed glial and sarcomatous elements occurring in intracranial neoplasms are well recognised and have been termed gliosarcomas. These tumours account for up to 8% of all glioblastomas. The sarcomatous elements are thought to derive from the neoplastic transformation of mesenchymal cells in or adjacent to the tumour. This transformation usually has the appearance of a fibrosarcoma or angiosarcoma. Alternative mesenchymal neoplastic differentiation may occur, however, giving rise to the appearances of chondrosarcoma and osteosarcoma. In 1969 Goldman described a case in which the sarcomatous elements of a mixed gliosarcoma appeared, on the basis of light microscopy alone, to differentiate towards skeletal muscle having the features of a rhabdomyosarcoma. He coined the term gliomyosarcoma. In 1986 Barnard et al reported a second case and demonstrated the features of rhabdomyosarcoma using the electron microscope. A further case characterised with both light microscopic and immunohistochemical techniques is reported.
Aged↗
Giant cell tumors of the sphenoid bone.
Giant cell tumors of the sphenoid are rare; there are 36 previously reported cases. We report two cases of these tumors in women in their thirties, both associated with pregnancy. In the first patient, the tumor was removed via a transnasal transsphenoidal approach. In the second patient, a Le Fort maxillotomy was required. In these cases, an interoperative diagnosis was made, and in both, this diagnosis directed surgical tactics towards a more radical excision. Reported experience with the outcome of giant cell tumors in other sites suggest that total removal by curettage is the ideal treatment; the main principle is to prevent local recurrence because the metastatic potential of this tumor is low. A combination of surgery and radiotherapy is essential for giant cell tumors occurring in sites where access is difficult, such as the sphenoid bone. Previous objections to radiotherapy have included poor response rate and malignant change. Recent studies suggest that neither of these problems is significant when modern therapeutic techniques are employed.
Adult↗
Is peroperative smear cytology necessary for CT-guided stereotaxic biopsy?
Neuropathology is a relatively scarce resource with uneven geographical distribution, and some surgeons rely on macroscopic appearances of tissue and await later paraffin section histology for the final diagnosis. The effect of the introduction of a peroperative cytology service has been assessed in a 5-year series of CT-directed stereotaxic biopsies of intracranial mass lesions using a low cost adapted pre-CT stereotaxic frame. The technique has been mastered by 28 different surgeons with varying degrees of neurosurgical expertise and 259 procedures have been performed in 245 patients. Benign lesions were detected in 24 (9.8%) patients, confirming the importance of making a histological diagnosis prior to initiating treatment. Permanent morbidity was 6.5% and mortality 3.3% and morbidity was balanced by an improvement in 19.6% of the patients following the procedure. For the first 142 patients no peroperative histological diagnosis was available and a diagnostic rate of 86.6% was achieved. For the last 103 patients the availability of peroperative smears improved the diagnostic rate to 94.2% and reduced the number of second biopsies needed for diagnosis from seven to zero. Our series demonstrates the need for peroperative cytology in CT stereotaxic biopsies, and confirms that a complete neuropathology service is a prerequisite for neurosurgical patient care.
Adolescent↗
Intradiploic meningiomas. A radiological study of two cases confirmed histologically.
Approximately 1% of meningiomas arise in extradural sites. Intradiploic meningiomas form only a very small proportion of this number. They tend to occur in young patients. The CT and MRI appearances, although unusual, may be characteristic of the condition. We present two cases and describe the CT and MR appearance; the latter has not previously been described.
Adult↗
Giant cell tumour of the sphenoid sinus: an unusual skull base tumour.
An unusual skull base tumour is presented. Intraoperative smears made the diagnosis and dictated a change in surgical strategy. Giant-cell tumours of the sphenoid bone are discussed, together with current management.
Adult↗
Improved access to lesions of the central skull base by mobilization of the zygoma: experience with 54 cases.
Improved access to lesions at the medial end of the sphenoid wing or in the interpeduncular cistern after mobilization of the zygoma has been a subject of growing interest in recent years. This study describes the operative technique we have adopted and records our experience with 55 operations in 54 patients who underwent the procedure in the past 3 years. Seven patients had vascular lesions, 44 had tumors, and 3 had miscellaneous lesions. The majority of the tumors were medial meningiomas, and particular note is made of those arising from the cavernous sinus with respect to their resectability. Sixteen of these tumors were encountered, and total excision was possible in 11 cases. Access to the infratemporal fossa is facilitated, and in 2 cases we were able to excise completely trigeminal neuromas that had extended there. The extra maneuver adds little to the overall operating time, and complications relating to it are uncommon, mild in degree, and usually self-limiting. We conclude that the operation is extremely valuable in appropriate circumstances.
Adolescent↗
Multiple cerebral abscesses.
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Anti-Bacterial Agents↗
Craniocervical stabilization using Luque/Hartshill rectangles.
Untreated craniocervical instability is associated with a high morbidity and a significant mortality. Existing methods using bone grafts, interlaminar wires, or acrylic eventually produce stability but require prolonged periods of immobility and have a high failure rate. The ideal method of fixation should provide for permanent correction of deformity and relief of symptoms, with immediate stabilization, at a single procedure. Posterior fixation of the occiput to a stable part of the cervical spine with a molded metal rectangle held in place by interlaminar wires was used to accomplish this. We report 20 patients treated consecutively who have undergone craniocervical fusion by this method using Luque/Hartshill rectangles. Fourteen patients had preexisting atlantoaxial instability and 6 had cord compression, but would become unstable after decompression. All operations were performed under general anesthesia; 9 patients (40%) were awake for intubation/positioning, and 7 patients had a simultaneous decompression. Sixteen patients made an uncomplicated recovery and became mobile 3 days postoperatively. Symptomatic and neurological improvement occurred in 70% of all patients. Neurological complications occurred in 4 patients (20%), reflecting the serious nature of the condition; 2 patients (10%) showed no change. Scrutiny of their presentations and operations failed to identify avoidable risk factors, except faulty wiring techniques. In all patients, permanent stabilization was achieved immediately, facilitating early mobilization with a real chance of improvement, which indicates that the method merits wider application.
Adolescent↗
Digital subtraction cisternography: a new approach to fistula localisation in cerebrospinal fluid rhinorrhoea.
Positive contrast cisternography with digital subtraction of fluoroscopy images before computed tomography (CT) was employed in the investigation of eight patients with cerebrospinal fluid (CSF) rhinorrhoea. Fistulae were visualised by preliminary digital subtraction cisternography (DSC) in six patients and in five patients the sites of leakage were confirmed at surgery. Fluoroscopy facilitated interpretation of CT in all the positive studies and in two patients provided information which could not be deduced from CT cisternography (CTC) alone. The combined technique is recommended for the investigation of patients with recurrent and post operative CSF rhinorrhoea and when CTC alone fails to identify the site of leakage.
Adult↗
Numb clumsy hands may indicate a surgically treatable cause of myelopathy in the elderly.
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Aged↗
A scale for neurosurgical audit.
A neurosurgical audit scale has been devised to provide a measure of disability and outcome. The audit scale was tested for observer variation and sensitivity against the Karnofsky scale, the Rosser disability scale and the Rosser distress scale. The highest ratio of observer concurrence compared with chance was noted for the neurosurgical audit scale, and the lowest ratio for the Rosser distress score. Sensitivity was almost identical for each of the scales. The neurosurgical audit scale lends itself to audit based on a computer database for which the input is the discharge summary. This achieves audit without additional work for either medical or secretarial staff.
Disability Evaluation↗
Synchronous vertebral decompression and posterior stabilization in the treatment of spinal malignancy.
Thirty-four patients with metastatic tumors of the spinal column exhibiting vertebral collapse and posterior element disease were treated by a single-stage operation combining decompression of the vertebral body with posterior spinal instrumentation. Attention is drawn to the use of computed tomographic scanning in planning the operative approach. The indications for surgery were neurological deficit in 32 patients and pain in 2; 14 patients received preoperative radiotherapy. Of the 21 patients who were nonambulant preoperatively, 67% walked again, 21% regained sphincter control, and 68% had less pain. The surgical mortality was 12%; wound infection and dehiscence occurred in 15%. These results indicate that a single-stage decompression and posterior stabilization may improve neurological function dramatically in patients with malignant cord compression. The operative morbidity and mortality is comparable to that of laminectomy.
Adolescent↗
Anterior decompression and stabilization of the spine in malignant disease.
Evidence has accumulated that indicates that laminectomy with or without radiotherapy is not necessarily the best mode of treatment for all cases of spinal cord compression of malignant pathogenesis. Success is limited, and there is a high risk of adverse neurological developments, particularly where there is anterior vertebral collapse. A prospective series of 26 consecutive patients with neurological complications of neoplastic extradural cord compression is described. Anterior decompression followed by stabilization in a single stage procedure was selected as the most appropriate method of treatment for all 26 patients. Various techniques were used in the replacement of the excised vertebral body, including the use of two types of prosthesis created specifically for the purpose. Of the patients who were not ambulatory at the time of surgery, 62% became so postoperatively; 71% of those with intractable pain were pain free after surgery. The postoperative mortality rate was 30%, which reflected the poor condition of the patients; in light of this, the criteria for operative selection are reviewed. Neurological deterioration did not occur in any patient. The method is recommended, for selected patients, for the management of cord compression caused by collapse of the vertebral body. The patient's prospects of restored ability to walk after a single-stage operation are good, and the risk of adverse neurological effects is negligible.
Adolescent↗
A low cost system for performing CT stereotaxic brain biopsy.
The cost of commercially available CT-compatible frames for stereotaxic brain biopsy has limited their availability in the U.K. Our adaptation to a pre-CT stereotaxic frame that had been in use at Atkinson Morley's Hospital for 12 years, and the availability of a GE 9800 CT scanner has allowed us to carry out accurate CT-directed stereotaxic biopsy at minimal cost. The system has the additional advantage of speed and ease of use in inexperienced neurosurgical hands. Biopsies in 100 patients have been performed by 12 different surgeons (80% by registrars) who mastered the technique without difficulty. The rates of permanent morbidity (4%) and mortality (2%) are low, the two mortalities occurring in patients with high grade astrocytomas. They compare very favourably with rates for freehand burr-hole biopsy, and our overall diagnostic success rate of 83% for the initial biopsies, rising to 90% as a result of re-biopsy in 10 of the patients, is similar to that achieved with much more costly commercial systems. Benign lesions were found in 7% of patients who would otherwise have been assumed to have malignant tumours, and this finding emphasises the value of achieving a histological diagnosis in every lesion of the brain.
Biopsy↗
Surgical management of midline skull-base tumors: a new approach.
Many surgical approaches to the clivus and upper cervical spine have been used in the treatment of skull-base tumors over the past 50 years. However, the outcome of surgery has been complicated by difficulties of access to the whole clivus, together with pharyngeal wound breakdown with subsequent development of cerebrospinal fluid (CSF) fistula and meningitis. A technique described recently utilized Le Fort I osteotomy to improve exposure of the clivus in the approach to vertebrobasilar aneurysms, facilitating control of the aneurysm and reducing the risk of posttraumatic CSF fistula. The same approach, via maxillotomy, has permitted partial or total tumor resection in 13 consecutive procedures carried out at Atkinson Morley's Hospital on 10 patients presenting with tumors of the skull base. Neurological status was either improved or unchanged in all patients postoperatively, and pain relief was obtained in five of eight cases in which this was a presenting symptom. No patient developed a CSF fistula following surgery. Cosmetic results were good, and no problems related to malocclusion were reported. This approach may be used to advantage in the surgical treatment of skull-base tumors, at initial presentation, and can be repeated without undue difficulty should there be tumor recurrence.
Adult↗
Neurosurgery for cervical spondylosis.
The pathogenesis of radiculopathy and myelopathy secondary to cervical spondylosis is described, together with the clinical features of these conditions and the factors that influence their natural history. After discussing the differential diagnosis the medical management and the indications for surgery are considered. Details of the operative approaches are presented in association with the results of treatment.
Humans↗
Application of radioimmunoassay to monitor treatment of human cerebral gliomas with bleomycin entrapped within liposomes.
A radioimmunoassay was assessed for its suitability for monitoring the blood and urinary concentrations of bleomycin entrapped within large unilamellar liposomes in patients receiving therapeutic doses of the drug. Bleomycin entrapped within liposomes was administered by direct intracerebral injection to three patients with grade III to IV cerebral gliomas, twice weekly for up to six weeks. No clinically important toxic effects were observed which could have been attributed to these preparations, although all three patients showed progressive deterioration in their clinical condition. This type of treatment may be more beneficial to patients at an earlier stage of their disease.
Adolescent↗