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R E Maxwell

Publications and source records attributed to R E Maxwell.

At least 19 recordsLinked to original sources
PubMed2003

Influence of 1.5-Tesla intraoperative MR imaging on surgical decision making.

To determine the frequency that high-field magnetic resonance (MR) imaging sequences influenced surgical decision making during intraoperative MR-guided surgery. From January 1997 to February 2001, 346 MR-guided procedures were performed using a 1.5-Tesla MR system (NT-ACS, Philips Medical Systems). This system can perform functional MR imaging (fMRI), diffusion weighted imaging (DWI), MR spectroscopy (MRS), MR angiography (MRA), and MR venography (MRV) in addition to T1-weighted, T2-weighted, and turbo FLAIR (fluid-attenuated inversion recovery) imaging. FMRI was used to determine areas of brain activation for language, motor function, and memory. DWI was utilized after tumor resection to exclude cerebral ischemia or infarction. MRS was obtained to identify areas of elevated choline that were suspected to correlate with tumor presence. MRA and MRV localized vascular structures adjacent to tumors prior to resection. The intraoperative procedures performed included 140 brain biopsies of which 82 utilized a trajectory guide and prospective stereotaxy. MRS was used in 42 biopsies (30%), of which 29 had turbo spectroscopic imaging (TSI) and 21 had single voxel spectroscopy (SVS). In all biopsy cases, diagnostic tissue was obtained. There were 103 tumor resections of which 18 (17%) had MRS. Functional MRI was used in 17 cases; 3 biopsies (2%) and 14 planned resections (14%). Speech function was localized in 3 cases, memory function in 3, and motor function in 11. In one case where the motor function of the tongue was intimately involved with a low-grade glioma, resection was not attempted. DWI was used in less than 10% of tumor resections. MRA and MRV were performed in 3 (3%) and 2 (2%) of tumor resections, respectively. The imaging capabilities (i.e., fMRI, DWI, MRA, MRV) associated with high-field intraoperative MR influenced surgical decision making primarily for tumor resections. MRS influenced target selection during brain biopsy.

Biopsy↗
PubMed2001

Brain biopsy sampling by using prospective stereotaxis and a trajectory guide.

OBJECT: The authors describe their initial results obtained using a skull-mounted trajectory guide for intraoperative magnetic resonance (MR) imaging-guided brain biopsy sampling. The device was used in conjunction with a new methodology known as prospective stereotaxis for surgical trajectory alignment. METHODS: Between January 1999 and March 2000, 38 patients underwent 40 brain biopsy procedures in which prospective stereotaxis was performed with the trajectory guide in a short-bore 1.5-tesla MR imager. In most cases, orthogonal T2-weighted half-Fourier acquisition single-shot turbo spin-echo (HASTE) images were used to determine the desired trajectory and align the device. The surgical trajectory was defined as a line connecting three points: the target, pivot, and alignment stem points. In all cases, surgical specimens were submitted for frozen section and pathological examination. Postoperative turbofluid-attenuated inversion-recovery and gradient-echo images were obtained to exclude the presence of hemorrhage. Trajectory determination and alignment was simple and efficient, requiring less than 5 minutes. Confirmatory HASTE images were obtained along the biopsy needle as it was being advanced or after reaching the target. All biopsy procedures yielded diagnostic tissue. One patient with a lesion near the motor strip experienced a transient hemiparesis of the hand related to passage of the biopsy needle, and another sustained a fatal postoperative myocardial infarction. No patient suffered a clinically significant or radiologically visible hemorrhage. CONCLUSIONS: In combination with prospective stereotaxis, the trajectory guide provided a safe and accurate way to perform brain biopsy procedures.

Adolescent↗
PubMed2001

Minimally invasive procedures. Interventional MR image-guided functional neurosurgery.

Intraoperative MR imaging techniques have the potential to greatly improve the stereotactic methods used for functional neurosurgery. No longer are neurosurgeons and patients always constrained by uncomfortable head frames and conventional stereotaxy. Accuracy and complication avoidance are improved by intraoperative imaging. Safety of operative machinery and equipment in an MR imaging operative suite is attainable, even with deep brain stimulating electrodes in depth electrodes for epilepsy. Although cost-effectiveness remains to be determined (see article by Kucharczyk et al in this issue), the minor inconveniences of operating within an iMRI environment seem to be significantly outweighed by the benefits.

Brain↗
PubMed2000

Safety, efficacy, and functionality of high-field strength interventional magnetic resonance imaging for neurosurgery.

OBJECTIVE: Interventional magnetic resonance imaging (MRI) allows neurosurgeons to interactively perform surgery using MRI guidance. High-field strength (1.5-T) imaging permits exceptional observation of intracranial and spinal pathological features. The development of this technology and its application to a variety of neurosurgical procedures are described. METHODS: We report on the first 101 cases that were treated in the interventional MRI unit (between January 1997 and September 1998). These cases included 39 brain biopsies, 30 tumor resections, 9 functional neurosurgical cases, 8 cyst drainages, 5 laminectomies, and 10 miscellaneous cases. Patients ranged in age from 14 months to 84 years (median, 43 yr); 61 patients were male and 40 were female. Intraoperative functional techniques that were used to influence surgical decision-making included magnetic resonance spectroscopy, functional MRI, magnetic resonance angiography and venography, chemical shift imaging, and diffusion-weighted imaging. All surgery was performed using MRI-compatible instruments within the 5-gauss line and conventional instruments outside that line. RESULTS: All 39 brain biopsies yielded diagnostic tissue. Of the 30 tumor resections, 24 (80%) were considered radiographically complete. The incidence of serious complications was low and was comparable to that associated with conventional operating rooms. One patient developed a Propionibacterium acnes brain abscess 6 weeks after surgery and another patient experienced Staphylococcus aureus scalp cellulitis after a brain biopsy, yielding an infection rate of less than 2%. No clinically significant hemorrhage was observed in immediate postoperative imaging scans, although one patient developed a delayed hematoma after a thalamotomy. One patient experienced a stroke after resection of a hippocampal tumor. No untoward events were associated with MRI-compatible instrumentation or intraoperative patient monitoring. CONCLUSION: High-field (1.5-T) interventional MRI is a safe and effective technology for assisting neurosurgeons in achieving the goals of surgery. Preliminary results suggest that the functional capabilities of this technology can yield data that can significantly influence intraoperative neurosurgical decision-making. The rates of serious complications, such as infection, associated with this new technology were low.

Adolescent↗
PubMed2000

Brain tumor resection: intraoperative monitoring with high-field-strength MR imaging-initial results.

PURPOSE: To investigate the challenges and benefits of magnetic resonance (MR) imaging during brain tumor resection. MATERIALS AND METHODS: A short-bore 1.5-T MR system equipped with echo-planar-capable gradients was used in resection of brain tumors in 30 patients. MR sequences and need for contrast material enhancement were determined on the basis of the targeted lesion. MR images were acquired before, during, and after surgery. Tissue obtained at biopsy or excised as a result of intraoperative MR findings was examined histopathologically. RESULTS: MR images of enhancing lesions proved to be the most challenging to interpret intraoperatively, and relative enhancement at the resection cavity boundary was not specific for residual tumor. The ability to detect residual tumor intraoperatively resulted in a radiologically complete resection in 24 (80%) of 30 patients. The frequency of complications was low, and no untoward effects related to the MR environment were observed. CONCLUSION: Intraoperative MR imaging provided valuable information on the completeness of resection, and resection progress was well demonstrated during surgery.

Adolescent↗
PubMed1999

Brain biopsy using high-field strength interventional magnetic resonance imaging.

OBJECTIVE: Lesions within the brain are commonly sampled using stereotactic techniques. The advent of interventional magnetic resonance imaging (MRI) now allows neurosurgeons to interactively investigate specific regions, with exquisite observational detail. We evaluated the safety and efficacy of this new surgical approach. METHODS: Between January 1997 and June 1998, 35 brain biopsies were performed in a high-field strength interventional MRI unit. All biopsies were performed using MRI-compatible instrumentation. Interactive scanning was used to confirm accurate positioning of the biopsy needle within the region of interest. Intraoperative pathological examination of the biopsy specimens was performed to verify the presence of diagnostic tissue, and intra- and postoperative imaging was performed to exclude the presence of intraoperative hemorrhage. Recently, magnetic resonance spectroscopic targeting was used for six patients. RESULTS: Diagnostic tissue was obtained in all 35 brain biopsies and was used in therapeutic decision-making. Histological diagnoses included 28 primary brain tumors (12 glioblastomas multiforme, 9 oligodendrogliomas, 2 anaplastic astrocytomas, 2 astrocytomas, 1 lymphoma, and 1 anaplastic oligodendroglioma), 1 melanoma brain metastasis, 1 cavernous sinus meningioma, 1 cerebral infarction, 1 demyelinating process, and 3 cases of radiation necrosis. In all cases, magnetic resonance spectroscopy was accurate in distinguishing recurrent tumors (five cases) from radiation necrosis (one case). No patient sustained clinically or radiologically significant hemorrhage, as determined by intraoperative imaging performed immediately after the biopsy. One patient (3%) suffered transient hemiparesis after a pontine biopsy for investigation of a brain stem glioma. Another patient developed scalp cellulitis, with possible intracranial extension, 3 weeks after the biopsy; this condition was effectively treated with antibiotic therapy. Three patients were discharged on the day of the biopsy. CONCLUSION: Interventional 1.5-T MRI is a safe and effective method for evaluating lesions of the brain. Magnetic resonance spectroscopic targeting is likely to augment the diagnostic yield of brain biopsies.

Adolescent↗
PubMed1998

Investigation of intraoperative brain deformation using a 1.5-T interventional MR system: preliminary results.

All image-guided neurosurgical systems that we are aware of assume that the head and its contents behave as a rigid body. It is important to measure intraoperative brain deformation (brain shift) to provide some indication of the application accuracy of image-guided surgical systems, and also to provide data to develop and validate nonrigid registration algorithms to correct for such deformation. We are collecting data from patients undergoing neurosurgery in a high-field (1.5 T) interventional magnetic resonance (MR) scanner. High-contrast and high-resolution gradient-echo MR image volumes are collected immediately prior to surgery, during surgery, and at the end of surgery, with the patient intubated and lying on the operating table in the operative position. In this paper we report initial results from six patients: one freehand biopsy, one stereotactic functional procedure, and four resections. We investigate intraoperative brain deformation by examining threshold boundary overlays and difference images and by measuring ventricular volume. We also present preliminary results obtained using a nonrigid registration algorithm to quantify deformation. We found that some cases had much greater deformation than others, and also that, regardless of the procedure, there was very little deformation of the midline, the tentorium, the hemisphere contralateral to the procedure, and ipsilateral structures except those that are within 1 cm of the lesion or are gravitationally above the surgical site.

Adult↗
PubMed1998

High-field strength interventional magnetic resonance imaging for pediatric neurosurgery.

BACKGROUND: Interventional magnetic resonance (MR) imaging allows neurosurgeons to interactively perform surgery using MR guidance. High-field (1.5-Tesla) strength imaging provides exceptional visualization of intracranial and spinal pathology. The full capabilities of this technology for pediatric neurosurgery have not been defined or determined. MATERIALS AND METHODS: From January 1997 through June 1998, 10 of 85 cases performed in the interventional MR unit were in the pediatric population (mean age 8.3, median 8, range 2-15 years). Procedures included 2 brain biopsies, 5 craniotomies for tumor, 2 thoracic laminectomies for syringomyelia, and placement of a reservoir into a cystic brainstem tumor. The biopsies and reservoir placement were performed using MR-compatible equipment. Craniotomies and spinal surgery were performed with conventional instrumentation outside the 5-Gauss magnetic footprint. Interactive and intraoperative imaging was performed to assess the goals of surgery. RESULTS: Both brain biopsies were diagnostic for cerebral infarct and anaplastic astrocytoma and the reservoir was optimally placed within the tumor cyst. Of the 5 tumor resections, all were considered radiographically complete. One biopsy patient and 1 tumor resection patient experienced transient neurological deficits after surgery. The patient with the thoracic syrinx required reoperation when the syringosubarachnoid shunt migrated into the syrinx 3 months after initial placement. No patient sustained a postoperative hemorrhage. Tumor histologies found at craniotomy were craniopharyngioma, ganglioglioma, and 3 low-grade gliomas. No evidence of tumor progression has been seen in any of these patients at a mean follow-up of 5.3 (range 4-8) months. The goals of the procedure were achieved in all 10 cases. There were no untoward events experienced related to MR-compatible instrumentation or intraoperative patient monitoring, despite the present inability to monitor core body temperature. CONCLUSIONS: 1.5-Tesla interventional MR is a safe and effective technology for assisting neurosurgeons to achieve the goals of pediatric neurosurgery. Preliminary results suggest that surgical resection of histologically benign tumors is enhanced in the interventional MR unit. The incidence of surgically related morbidity is low.

Adolescent↗
PubMed1995

Language function after temporal lobectomy without stimulation mapping of cortical function.

We studied 95 patients who underwent standard anterior temporal lobectomy (ATL) without stimulation mapping of language areas, using neuropsychological parameters of language function preoperatively and 1 year postoperatively [Boston Naming Test and Verbal Fluency, and the Information, Comprehension, Arithmetic, Similarities, Digit Span, and Vocabulary subtests of the Wechsler Adult Intelligence Scale (WAIS)]. Verbal IQ (VIQ), Performance IQ (PIQ), Full-Scale IQ (FSIQ), and Verbal Deviation Quotient were also evaluated, as were parameters of memory function. All patients had hemisphere dominance for language assessed by an intracarotid amytal test. Fifty-three patients had a left dominant (LHDL) ATL with a mean extent of lateral resection of 4.8 cm, and 10 had a left ATL with right or mixed hemisphere dominance (RHDL, MDL). Thirty-two patients had a right nondominant ATL. Seizure outcome was 57 and 59% seizure-free for LHDH and right nondominant group, respectively, 1 year after operation. Comparison of preoperative scores showed the LHDL group to have significantly lower scores than the right nondominant group for several parameters of language function and memory. The group undergoing left dominant ATL showed no significant loss of language function postoperatively and actually showed gains in many parameters. Standard ATL without stimulation mapping of language areas and with conservative lateral resection is safe for long-term language function. In addition, evidence shows preexisting language dysfunction in patients undergoing left dominant ATL.

Adolescent↗
PubMed1995

Cyclosporine A toxicity presenting with acute cerebellar edema and brainstem compression. Case report.

A 38-year-old man receiving cyclosporine A after bilateral lung transplantation for cystic fibrosis presented with cortical blindness, generalized seizures, and cerebellar edema. Progressive brainstem compression necessitated emergency posterior fossa decompression. Replacement of cyclosporine A with an alternative immunosuppressive agent, FK506, was followed by rapid neurological recovery and dramatic resolution of radiographic abnormalities. The etiology, clinical features, and radiographic findings of cyclosporine A neurotoxicity are discussed. The pertinent literature is reviewed.

Acute Disease↗
PubMed1994

Language function following subdural grid-directed temporal lobectomy.

The purpose of the study was to determine the extent to which a temporal resection may be undertaken without producing risk to temporal language areas. Patients undergoing craniotomy and placement of a subdural electrode array (SEA) for evaluation of intractable epilepsy were studied to determine the variability of distance of temporal language cortex from the temporal pole. Hemisphere dominance was determined by intracarotid sodium amytal injection. Temporal lobe speech arrest (SA) was mapped with a 64 contact point SEA. Thirty-one patients had left dominant hemisphere SEAs. Thirty had SA 5 cm to 9 cm from the temporal pole (median 7 cm). One had SA at 3 cm. Twenty-one patients subsequently had temporal lobectomy (TL). Mean extent of resection was 5.7 cm (range 3 to 9 cm). In 18 TL patients who had neuropsychometric evaluation of language function pre- and post-surgery, there was no significant deterioration. Thirty-nine patients had right non-dominant SEAs placed. Eighteen had TL. Thirteen of these had pre- and post-surgery language evaluation and there was no significant change. Comparison of preoperative scores showed significant superiority of the right non-dominant group over the left dominant group for naming. TL up to 5 cm without stimulation mapping of language areas would be safe in the majority of cases, but one subject (3%) had SA mapped anterior to this and a small number of cases may therefore be at risk to language function following a 5 cm TL. Extensive lateral resections up to 9 cm are possible with preservation of language function with stimulation cortical mapping.

Adolescent↗
PubMed1994

Pleomorphic xanthoastrocytoma--report of four cases, with MRI scan appearances and literature review.

Pleomorphic xanthoastrocytoma (PXA) is a rare glial tumour typically occurring in young patients in the first three decades, having a superficial cortical location and with a relatively good prognosis for long-term survival. Four cases are reviewed. The magnetic resonance imaging (MRI) appearances, which in PXA have been reported only once before, are described in three cases. The fourth case was studied by computed tomography and angiography. One patient developed seizures at age 2 days and was aged 2 1/2 years at presentation. This is the youngest patient with PXA yet reported. Three of the four patients had seizures, but in one case the tumour was not the cause of the seizures. Review of the literature has revealed 47 reported cases. Mean age at presentation was 14.3 years. Epilepsy occurred in 78%. Seventeen patients were alive without recurrence at a mean of 7.9 years after diagnosis and 10 patients died at a mean of 7.4 years after diagnosis. Thirteen cases had recurrence at a mean of 6 years after surgery and in five instances the recurrence was in the form of a glioblastoma. Resections which were grossly total were less likely to develop recurrence than those which were subtotal. Complete gross resection of tumour offers the best therapeutic option in PXA.

Adolescent↗
PubMed1993

Targeted brain biopsy: a comparison of freehand computed tomography-guided and stereotactic techniques.

With computed tomography (CT) and magnetic resonance imaging stereotactic systems, biopsies of intracranial lesions can be made with safety and ease. Before the development of this technique, neurosurgeons often performed freehand brain biopsies under CT guidance. While stereotactic biopsy is the procedure of choice for small, deep lesions, few studies have compared the morbidity, mortality, and efficacy in obtaining a diagnosis associated with these two techniques for superficial lesions. A total of 167 consecutive CT-guided or stereotactic brain biopsies were performed in 154 patients. Fourteen of the stereotactic and 12 of the CT-guided biopsies were of deep lesions and were excluded from analysis. The results of 75 freehand CT-guided biopsies of superficial lesions in 69 patients were compared with those of 66 stereotactic biopsies (34 CT-guided and 32 MRI-guided) performed with the Brown-Roberts-Wells stereotactic system in 60 patients. Twenty-five of the lesions in the stereotactic biopsy group measured < or = 2 cm, as compared with 13 of those in the freehand CT-guided biopsy group. There were no biopsy-related deaths among the patients who underwent freehand CT-guided biopsy and one death among those who underwent stereotactic biopsy (1.5%). Freehand CT-guided biopsy was associated with 5% morbidity, compared with 6% morbidity for stereotactic biopsy. Seven CT-guided needle biopsies (9%) and 12 stereotactic biopsies (18%) were nondiagnostic. Statistical analysis showed no significant difference between morbidity and mortality in the two groups, but the rate of diagnostic failure was significant (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1993

Hemispherectomy for intractable seizures: long-term results in 17 patients followed for up to 38 years.

Seventeen patients who underwent hemispherectomy for intractable epilepsy between 1950 and 1971 were reviewed to evaluate outcome for seizure control and the development of late complications. Sixteen had complete resection and in one the frontal pole was preserved. The follow-up period was 19 to 38 years (mean 28 years). One patient was lost to follow-up review 10 years after surgery. Three patients had died but none of the deaths were related to the surgery or to epilepsy. Ten patients had no postoperative complications, and three developed late complications: two had elevated intracranial pressure with enlargement of the remaining lateral ventricle after 13 and 16 years, and one had recurrent bleeding into the cerebrospinal fluid after 6 years. All were treated surgically and have since remained well. Eight patients (47%) had no seizures after surgery and eight (47%) were almost seizure-free. It is concluded that classical hemispherectomy is an effective operation for control of some types of epilepsy. The late complications, which occurred in 17% of the cases in this series, can be successfully treated. This series presents the longest follow-up results after hemispherectomy reported to date.

Adolescent↗
PubMed1991

The prognostic value of residual spikes in the postexcision electrocorticogram after temporal lobectomy.

We correlated the postresection electrocorticograms (ECoGs) of 80 patients who underwent temporal lobectomy under general anesthesia for treatment of intractable complex partial seizures with surgical results in three groups: seizure/aura free (32 patients), auras only (16 patients), and one or more postoperative seizures (32 patients) at mean follow-up times of 34, 31, and 38 months, respectively. Spontaneous "residual spikes," ie, present after all resections, were present in 47% of patients who had no postoperative seizures or auras. However, they occurred in 72% of patients with any postoperative seizures (p less than 0.05). The location (convexity, mesial, or edge of resections) or the distribution (unifocal versus multifocal) of the residual spikes was not of prognostic value. Quantitative studies in 5-minute epochs of the postexcision ECoGs did not reveal a significant difference in the morphology of the residual spikes, ie, the amplitude or firing pattern (single versus polyspike), in the three groups. The group with postoperative seizures showed a higher number of spikes per epoch (greater than or equal to 50), but it was not significant. Although the study shows that patients with residual spikes may have good prognosis, they are at significantly higher risk for postoperative seizures as compared with those without residual spikes. The possibility that intensity of firing of residual spikes may be an additional predictor of outcome warrants further study.

Cerebral Cortex↗
PubMed1987

Magnetic resonance imaging in the assessment and surgical management of epilepsy and functional neurological disorders.

Magnetic resonance imaging (MRI) offers significant advantages over computerized tomography (CT) and teleradiographic techniques when used for the evaluation and management of epilepsy and functional neurological disorders. Depth recording and radiofrequency electrodes can be more accurately positioned within structures such as the amygdala and hippocampus. The extent of corpus callosum section, lobectomy, topectomy, and radiofrequency stereotactic lesions can now be readily confirmed and related with seizure, neurological, and behavioral outcome. Occult, usually low grade, intraparenchymal neoplasms not visualized on CT scans can be located by MRI and biopsied or excised by MRI stereotactic techniques.

Corpus Callosum↗
PubMed1987

Neuroschisis of the cervical spinal cord in a patient with Klippel-Feil syndrome.

During the neurological work-up of a young patient with Klippel-Feil syndrome, the presence of a neuroschisis of the cervical spinal cord was detected. The patient presented with a transient and acute hemisensory loss and a Horner's syndrome of the opposite side. The unusual presentation and radiological findings in a patient with Klippel-Feil syndrome prompted this report.

Adult↗