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Biomedical subjects

F J Epstein

Publications and source records attributed to F J Epstein.

At least 55 records · Page 3Linked to original sources
PubMed1995

Complications of fourth-ventricular shunts.

Fourth-ventricular shunting is commonly used to treat symptomatic posterior fossa cysts of the Dandy-Walker malformation and trapped fourth ventricle. Although the benefits of this procedure have been widely reported, there is a paucity of data on the pitfalls of posterior fossa shunting in the neurosurgical literature. During the 4-year period from July 1989 to June 1993, we placed fourth-ventricular shunts in 12 patients. Remarkably, 5 patients suffered complications related to posterior fossa catheter placement (42% rate). Three of these patients developed new cranial nerve dysfunction caused by direct injury to the floor of the fourth ventricle, 1 patient suffered an intracystic hemorrhage and acute shunt malfunction, and 1 patient had the catheter tip in the brainstem on postoperative studies without new neurological deficit. We conclude that placement of fourth-ventricular shunts can be fraught with complications which we believe is related to technique. We propose that altering the trajectory of the ventricular catheter from our usual midline technique to a more lateral position will lessen the chances for injury to the floor of the fourth ventricle. In this manner we hope to decrease our incidence of complications for this procedure.

Adult↗
PubMed1995

Brain stem mapping: neurophysiological localization of motor nuclei on the floor of the fourth ventricle.

We have improved upon a brain stem mapping technique that can be used to locate cranial motor nuclei on the floor of the fourth ventricle. This technique helped to intraoperatively locate the facial colliculus and the motor nuclei of cranial nerves IX/X and XII in 14 patients undergoing removal of brain stem tumors. The motor nuclei of these cranial nerves are usually located relative to specific anatomic landmarks on the ventricular floor. These landmarks were not evident in most patients studied because of the distorting effects of the tumor. Different points of the floor of the fourth ventricle were electrically stimulated while electromyographic responses were recorded with electrodes inserted in the orbicularis oculi and orbicularis oris muscles, the lateral posterior pharyngeal wall, and the intrinsic muscles of tongue. Mapping was performed before and after tumor resection. The technique was found to be useful for locating cranial motor nuclei before tumor resection. It enabled surgeons to avoid damaging the nuclei when entering the brain stem. This technique, however, has certain limitations. Because this is a mapping technique, not a monitoring technique, continuous monitoring during tumor resection was unavailable. Also, the presence of a muscle response after tumor resection did not always indicate preservation of immediate postoperative function (7 days after surgery) because damage to the corticobulbar tract and/or the underlying neural circuitry was not detectable by mapping. Further research is needed to determine the point of stimulation in the functional motor circuitry and the relationship between intraoperative recordings and postoperative function in the long term.

Adolescent↗
PubMed1995

Intramedullary spinal cord lipomas.

Spinal cord lipomas are rare lesions, accounting for approximately 1% of all spinal cord tumors. True intramedullary spinal cord lipomas are extremely rare and are represented in the literature as scattered, single case reports. The authors present a series of six patients with intramedullary spinal cord lipomas managed at our institution from July, 1985 to July, 1993. The patients' ages ranged from 8 to 45 years. Four patients presented with newly diagnosed tumors and two had undergone previous surgery. Patients usually presented with long histories of disability followed by rapid progression of their symptoms. Most patients were in poor neurological condition on presentation. Presenting symptoms included spinal pain, dysesthetic sensory changes, gait difficulties, weakness, and incontinence. Three patients had cervical tumors, two had cervicothoracic tumors, and one patient had a thoracic tumor. Diagnostic studies, including magnetic resonance imaging, were obtained in all patients. No patient exhibited any form of spinal dysraphism or had a dural defect. All patients underwent decompressive, subtotal resections of 40% to 70% of their lesions. Follow-up times ranged from 12 to 96 months. All patients had resolution of their pain, but they generally showed no neurological improvement. As of their most recent follow-up visit, none of the patients was neurologically normal; three can function independently, although with neurological deficits. The other three patients cannot function independently and have severe neurological deficits. The authors conclude that patients with intramedullary spinal cord lipoma who present with significant neurological compromise have a very poor prognosis with regard to neurological function and generally show no improvement with surgical resection.

Adolescent↗
PubMed1995

Twenty-year experience with early surgery for craniosynostosis: II. The craniofacial synostosis syndromes and pansynostosis--results and unsolved problems.

As the second of a two-part series, 76 patients with pansynostosis and craniofacial synostosis syndromes were retrospectively analyzed. Diagnoses included pansynostosis (7), craniofrontonasal dysplasia (8), and Apert (24), Crouzon (15), and Pfeiffer (15) syndromes. All patients underwent primary fronto-orbital advancement-calvarial vault remodeling procedures at less than 18 months of age (mean 6.1 months). Twenty-eight patients (36.8 percent) required a secondary cranial vault operation (mean age 28.4 months). Additionally, a major tertiary procedure was necessary in 5 patients to deal with persistent unacceptable craniofacial form. To address the associated finding of midface hypoplasia, 64.8 percent (n = 35) of patients underwent Le Fort III midface advancement or had that procedure recommended for them. The remainder were awaiting appropriate age for this reconstruction. The more extensive pathologic involvement of the pansynostosis and craniofacial syndrome group is illustrated. As compared with the isolated craniofacial synostosis group previously reported, the incidence of major secondary procedures (36.8 versus 13.5 percent), perioperative complications (11.3 versus 5.0 percent), follow-up complications (44.7 versus 7.7 percent), hydrocephalus (42.1 versus 3.9 percent), shunt placement (22.4 versus 1.0 percent), and seizures (11.8 versus 2.9 percent) was significantly increased. Complex problems including those of increased intracranial pressure, airway obstruction, and recurrent turricephaly or cranial vault maldevelopment are repeatedly encountered. In addition, that early fronto-orbital advancement-cranial vault remodeling failed to promote midface development and hypoplasia of this region is almost a consistent finding in the craniofacial syndromic group. The average length of postoperative follow-up was 6 years. According to the classification of Whitaker et al., which assesses surgical results, 73.7 percent of patients were considered to have at least satisfactory craniofacial form (category I-II) at latest evaluation. An algorithmic approach to the treatment of all patients with craniosynostosis is presented utilizing early surgical intervention as the key element.

Acrocephalosyndactylia↗
PubMed1994

How to get rid of the shunt: a comment.

The consensus of the speakers was that there is no single test that reliably confirms that a shunt is not functioning. They all agreed that shunt removal was always associated with an element of hazard and that it should not be carried out except in the most exceptional circumstances.

Cerebrospinal Fluid Pressure↗
PubMed1994

Management of hydrocephalus in children with medulloblastoma: prognostic factors for shunting.

Patients with medulloblastoma frequently present with hydrocephalus. While not all patients with medulloblastoma will continue to suffer from hydrocephalus after tumor resection, there is a significant proportion who will require a permanent shunt. We have retrospectively reviewed a group of children with medulloblastoma not shunted preoperatively, and have identified several characteristics which are associated with a requirement for permanent shunt. We studied 42 patients and found that 17 patients (40%) required permanent shunts within 4 weeks of craniotomy. The shunted patients were younger (5.4 +/- 2.9 vs. 10.0 +/- 5.7 years; p < 0.01), had larger ventricles (p < 0.05), and had more extensive tumors (Chang's stage T3 and T4; p < 0.01). These variables were all independently significant. In addition, we found that the patients requiring postcraniotomy shunts had a much higher rate of morbidity including a postoperative pseudobulbar syndrome. Of interest, we found that none of our patients without the above characteristics required a shunt. In particular, we found that no patient older than 10 years required a shunt. Thus, we conclude that younger patients with moderate to severe preoperative hydrocephalus and extensive tumors may benefit from perioperative CSF diversion. Other patients not meeting the above criteria can probably be safely managed with perioperative corticosteroids alone.

Adolescent↗
PubMed1994

Cervicomedullary tumors in children: a distinct subset of brainstem gliomas.

We reviewed the clinical course of 17 children who underwent surgical resection of an intra-axial cervicomedullary tumor between 1980 and 1992. The clinical symptoms, which reflected medullary dysfunction in nine children and cervical cord deficits in eight, were present for a mean of 2.1 years before diagnosis (range, 2 months to 7.5 years), and for at least 1 year in 80% of the patients. Neurodiagnostic imaging (MRI in 14, CT in 3) showed the tumor epicenter in the medulla in 11 and in the upper cervical cord in six. Surgery was performed for newly diagnosed tumor in 11 children, and for progressive disease in six who had received prior radiotherapy. The surgical resection was gross total in two and partial (60 to 95%) in fifteen. Fifteen patients had low-grade glial tumors (10 astrocytomas, four gangliogliomas, and one mixed glioma), and two had anaplastic gangliogliomas. Four-year progression-free and total survival rates after surgery for patients who had surgery as initial therapy were 70 and 100%; for those who had surgery at the time of progression, these were 41 and 62%. Postsurgical neurologic complications occurred in five children. Four of these children had received prior radiotherapy. Two of them already had severe preoperative deficits and three had moderate deficits that worsened after surgery. Twelve patients with mild deficits were unchanged or improved postoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)

Actuarial Analysis↗
PubMed1994

Focal tectal tumors: management and prognosis.

A 7-year review at our institution identified 12 children with midbrain tectal tumors. All presented with signs of increased intracranial pressure, had hydrocephalus on initial imaging, and were treated with ventriculoperitoneal (VP) shunts. Three had clinical and radiographic progression of disease. Two were treated with radiation and chemotherapy, with progression of disease in one. The third received radiation alone. All patients are alive, with a median follow-up of over 4 years. Median progression-free survival is at least 24 months and median total survival is beyond 50 months. The tectal glioma syndrome is a relatively benign variant of the brainstem glioma. The majority of patients may be managed with a VP shunt alone.

Adolescent↗
PubMed1994

Craniopharyngiomas: a clinicopathological analysis of factors predictive of recurrence and functional outcome.

Pathological and clinical data from 56 patients operated on for craniopharyngioma since 1981 were analyzed to determine the utility of dividing patients with this tumor into distinct clinical groups based on recognized pathological type and to determine the prognostic import of brain invasion. Of the tumors in the 30 adult patients, 66% were adamantinomatous, 28% were squamous papillary, and the remainder were mixed. However, of the tumors in the 26 children, 96% were adamantinomatous and none were pure squamous papillary (P < 0.01). Forty-six percent of the children compared with 17% of the adults had brain invasion (P < 0.01). Brain invasion was present in 37% of the adamantinomatous but in only 13% of the squamous papillary tumors. Seventy-seven percent of the children underwent gross total resection (GTR) compared with 27% of the adults (P < 0.01). Sixty-three percent of the squamous papillary tumors underwent GTR compared with 54% of the adamantinomatous and mixed tumors. Follow-up ranged from 7 to 187 months (mean, 49 mo). After subtotal resection, with or without radiation therapy, 58% of the tumors recurred compared with 17% recurrence after GTR (P < 0.01), with a mean time to recurrence of 34 months. In both tumor histological types, subtotal resection was associated with a higher rate of tumor recurrence compared with gross total resection. Among the subtotally resected craniopharyngiomas, 2 of the 3 (67%) squamous papillary and 11 of the 21 (52%) adamantinomatous and mixed tumors recurred. In contrast, among the totally resected tumors, none of the 5 squamous papillary and only 5 of the 25 (20%) adamantinomatous and mixed tumors recurred. There were no significant differences in Karnofsky performance status score, mortality rate, or visual and endocrine outcomes when comparing patients based on histological tumor type. When controlling for age and extent of resection, we found that brain invasion had no significant effect on recurrence rate in totally resected tumors. Based on the limited number of patients in this series, we conclude as follows. 1) Contrary to previous reports, squamous papillary craniopharyngiomas, like adamantinomatous tumors, may recur when subtotally resected. 2) For both tumor variants, the most significant factor associated with craniopharyngioma recurrence is the extent of surgical resection rather than histopathological subtype. 3) Contrary to prior hypotheses, brain invasion in totally resected tumors does not predict higher recurrence. 4) GTR is associated with a significantly lower recurrence rate and can be achieved without sacrificing functional outcome.

Adolescent↗
PubMed1993

Selective dorsal rhizotomy: outcome and complications in treating spastic cerebral palsy.

Selective dorsal rhizotomy has shown great promise as a treatment for the functional disabilities and deforming hypertonia of spastic cerebral palsy. At New York University Medical Center, 200 children underwent this procedure between 1986 and 1990. All groups, whether walkers, crawlers, or nonlocomotors, showed improvement in the tone and range of most muscles tested. Half of these patients experienced complications. Thirty-five of these were serious and included bronchospasm (5.5%), aspiration pneumonia (3.5%), urinary retention (7%), and sensory loss (2%). There are, however, clear indications that warn of these complications; monitoring and prophylactic treatment can minimize their effects, and the possibility of such problems is more than offset by the proven benefits of this operative procedure.

Cerebral Palsy↗
PubMed1993

Brain-stem glioma growth patterns.

During the last decade, several authors have reported that certain brain-stem gliomas may be associated with a better prognosis than others. In this paper, retrospective correlations between the pathological findings and the magnetic resonance (MR) imaging appearance of 88 brain-stem gliomas are established. The authors propose an anatomical hypothesis that helps identify glioma growth patterns in general and that clarifies why cervicomedullary, dorsally exophytic, and focal tumors have a more favorable prognosis. According to this hypothesis, growth of benign gliomas of the brain stem is guided by secondary structures such as the pia, fiber tracts, and the ependyma, which in turn leads to stereotypical growth patterns that are clearly identified on MR images. The authors believe that this hypothesis, in conjunction with clinical data, may help establish selection criteria for the surgical treatment of specific brain-stem lesions.

Brain Neoplasms↗
PubMed1993

The plated bayonet: a new instrument to facilitate surgery for intra-axial neoplasms of the spinal cord and brain stem. Technical note.

A new instrument for use in surgically treating intra-axial neoplasms of the spinal cord and brain stem is described. The plated bayonet allows neoplastic tissue in the spinal cord to be separated from functioning neural elements without perforating the adjacent spinal cord. In addition, the plated bayonet facilitates exposure through the very small incision necessary to remove tumors of the brain stem without damaging cranial nerves or other vital structures.

Brain Neoplasms↗
PubMed1993

Adult intramedullary spinal cord ependymomas: the result of surgery in 38 patients.

Thirty-eight patients underwent surgery for an intramedullary spinal cord ependymoma. In 37 patients, postoperative magnetic resonance imaging confirmed that the tumor was totally removed. The morbidity of surgery was directly related to the preoperative neurological condition. Patients who were normal or nearly normal preoperatively were rarely worse after surgery, and those who had significant disability preoperatively were at greatest risk of being more impaired after surgery. There has been no tumor recurrence in any patient after a mean follow-up period of 24 months, and radiation therapy has not been employed as a surgical adjunct.

Adult↗
PubMed1993

Central nervous system gangliogliomas. Part 1: Pathology.

Histopathological features that suggest the diagnosis of ganglioglioma require, in most cases, confirmation by special stains to distinguish these tumors from other gliomas. For this purpose, immunostaining for synaptophysin, which has previously been shown to selectively label the cell surface of neoplastic ganglion cells, was used to retrospectively examine glioma tumor specimens. Sixty-three cases of ganglioglioma were identified. The files of the Division of Neuropathology of New York University Medical Center contained 45 tumors that had been diagnosed as ganglioglioma, of which 42 were verified by synaptophysin; three cases were reclassified, two as astrocytomas and one as a gangliocytic paraganglioma. Thus, a tumor identified as ganglioglioma based on other criteria was likely to be a ganglioglioma. The other 21 cases of gangliogliomas were originally diagnosed as astrocytoma or mixed glioma, but were shown by synaptophysin staining to be gangliogliomas. In some cases the ultimate diagnosis was obtained after radical surgery provided relatively abundant amounts of tissue, thereby limiting sampling errors, in contrast to the biopsies from which the original diagnoses were made. Histopathological review of these cases demonstrated that four features represent important clues to the correct diagnosis: 1) clusters of large cells potentially representing neurons (without such cells the tumor cannot be classified as a ganglioglioma); 2) no perineuronal clustering of the glial cells around the alleged neoplastic neurons; 3) fibrosis (desmoplasia); and 4) calcification. Binucleate neurons, previously suggested to be common in gangliogliomas, were not frequently found in this series, and lymphocytic infiltrates, while common, are so often found in other tumors that they gave no specific hint that any single neoplasm was a ganglioglioma. The glial elements were astrocytic in all cases, except that one tumor also had oligodendroglial and ependymal patterns. Four tumors also had small mature neurons, as seen in neurocytomas. Cells from one tumor were successfully grown in short-term tissue culture; the culture contained large dividing neurons with synaptophysin immunoreactivity as well as smaller dividing cells, demonstrating that the neuronal cells are a proliferating element in gangliogliomas.

Adult↗
PubMed1993

Central nervous system gangliogliomas. Part 2: Clinical outcome.

The records of 58 patients with gangliogliomas surgically treated between January 1, 1980, and June 30, 1990, were retrospectively reviewed in order to determine long-term survival, event-free survival, and functional outcome resulting after radical resection and to assess the impact of histological grading on outcome. Tumors were located in the cerebral hemisphere in 19 cases, the spinal cord in 30, and the brain stem in nine. Forty-four patients had gross total resection and 14 had radical subtotal resection. Only six patients underwent postoperative irradiation or chemotherapy and, therefore, the outcome was generally related to surgery alone. Of the 58 gangliogliomas, 40 were classified as histological grade I, 16 were grade II, and two were grade III. The median follow-up period was 56 months. There were no operative deaths, and the operative morbidity rate was 5%, 37%, and 33% for cerebral hemisphere, spinal cord, and brain-stem gangliogliomas, respectively. The 5-year actuarial survival rates for cerebral hemisphere, spinal cord, and brain-stem gangliogliomas were 93%, 84%, and 73%, respectively (p = 0.7). The event-free survival rate at 5 years was 95% for cerebral hemisphere gangliogliomas and 36% for spinal cord gangliogliomas (p < 0.05); for brain-stem gangliogliomas the event-free survival rate at 3 years was 53% (p < 0.05). Neurological function at recent follow-up evaluation was stable or improved in 81% of patients. Multivariate analysis (Cox linear regression) revealed tumor location to be the only variable predictive of outcome, with spinal cord and brain-stem gangliogliomas having a 3.5- and 5-fold increased relative risk of recurrence, respectively, compared to cerebral hemisphere gangliogliomas. Histological grade was not predictive of outcome, although in each location there was a trend for higher-grade tumors to have a shorter time to recurrence. It is concluded that radical surgery leads to long-term survival of patients with gangliogliomas, regardless of location, and adjuvant therapy can probably be reserved for special cases.

Adolescent↗
PubMed1992

Osteoplastic laminotomy in children.

The article reviews 180 cases of osteoplastic laminotomies, 1 year after operation. The patients were predominantly children undergoing selective dorsal rhizotomies. Also included were a few pediatric patients who received laminotomies for spinal cord tumors. Spinal X-rays were reviewed at 1 and 3 years of follow-up. There was complete to partial bridging of the laminar roof in all cases. This experience confirms that the procedure is well tolerated and is associated with reossification of the replaced bony segment.

Adolescent↗
PubMed1992

Intraoperative monitoring of the dorsal sacral roots: minimizing the risk of iatrogenic micturition disorders.

In 31 children (age, 2-17 years) and 1 adult, individual dorsal root action potentials (DRAPs) from the S1-S3 roots were recorded intraoperatively after electrical stimulation of the dorsal penile or clitoral nerves, in preparation for surgery within the cauda equina. In most patients, pudendal afferent activity was present in S2 and S3 bilaterally; in some, the afferent activity was confined to a single root bilaterally, and in one, to a single root on one side. Dorsal root action potentials of small amplitude were recorded from S1 in 15 patients, although in no patient was S1 the primary carrier of these afferents. No lesion of the roots or rootlets carrying significant afferent activity was created during the rhizotomy, and no dysfunction in micturition resulted. We propose that the neurophysiological identification of roots and rootlets carrying afferent activity from the penile or clitoral nerves allows for rhizotomy of the S2 roots with the least possible risk of postoperative micturition and sexual dysfunction.

Adolescent↗