Radiosurgery and venous malformations.
Explore the source record for details and available documents.
Adult↗
Biomedical subjects
R F Spetzler
Publications and source records attributed to R F Spetzler.
Multicystic metastatic carcinoid to brain: case report.
Symptomatic intraparenchymal brain metastases from carcinoid tumors are unusual, and neurological deficits are rarely the first symptom of underlying carcinoid primaries. We report a patient with multiple cystic metastases to the brain from a lung primary who first presented with headaches and seizures. Serotonin was present within the fluid of the cystic cavities, and serum serotonin concentrations were normal. Magnetic resonance imaging of the brain revealed several metastases not present on the initial head computed tomography scan.
Aged↗
Cerebellar hemorrhage associated with capillary telangiectasia and venous angioma: a case report.
We report a case of recurrent cerebellar hemorrhage from a capillary telangiectasia associated with a venous angioma. Based on the findings in this case and a review of the literature, we concluded that the hemorrhage was from the telangiectasia and not from the associated venous angioma. The association between capillary telangiectasias and cavernous malformations and the established association of the latter with venous angiomas are reviewed. This case illustrates the complex interrelationship between these histologically distinct malformations and its influence on their potential to hemorrhage.
Adult↗
The effect of intrathecal sodium nitroprusside on severe chronic vasospasm.
The efficacy of sodium nitroprusside in resolving cerebral vasospasm was evaluated with multicisternal injections. Twelve animals received fresh, unheparinized arterial blood via three injections (15 ml total) into the cisterna magna. Selective vertebral arteriography was performed on Day 0, and blood injections were performed on the second and third days after the first injection. On the seventh day selective arteriography was performed to evaluate the diameter of the basilar artery. In the sodium nitroprusside group, intrathecal injections of the drug were started on Day 4 and continued for two days (25 micrograms/kg/day). The diameter of the basilar artery was reduced 72.98 +/- 11.07% in control experiments. For the animals treated with intrathecal sodium nitroprusside, the mean diameter of the basilar artery was reduced 29.25 +/- 4.54%. The effect of intrathecal sodium nitroprusside on intracranial pressure (ICP), blood pressure (BP) and electrocardiogram (ECG) was also evaluated in 14 animals. There were no prominent changes in ICP, BP, or ECG when sodium nitroprusside was given intrathecally, but BP decreased and ICP and heart rate increased with intravenous doses of sodium nitroprusside. These results support the hypothesis that sodium nitroprusside administered intrathecally is an effective treatment for cerebral vasospasm.
Animals↗
Traumatic occipitoatlantal dislocations.
Fourteen occipitoatlantal dislocations were treated during an 11-year period. All patients presented with neurological deficits and definite evidence of spinal instability. Plain radiographs provided the diagnosis conclusively in 11 patients. Three patients required computed tomography (CT) or magnetic resonance (MR) imaging for diagnosis. Rotational subluxations were radiographically occult and associated with less severe neurological injuries compared to distracted or translated subluxations. Ten patients died acutely. One patient, who had complete C1 level quadriplegia, died after 3 months. Three patients with incomplete spinal cord syndromes had long-term survival and functional neurological recoveries. Extensive ligamentous injury predisposed patients to recurrent subluxations. In several patients, traction or a cervical collar caused distraction and neurological injury. Halo immobilization and urgent fusion are necessary for patients with salvageable neurological function. Nonoperative measures are inadequate for immediate or long-term spinal stability.
Accidents, Traffic↗
Surgical decisions on the basis of magnetic resonance angiography of the carotid arteries.
The recent demonstration of the efficacy of carotid endarterectomy in certain patients emphasizes the advantages of having a noninvasive, accurate means of evaluating the carotid arteries. Advances in magnetic resonance (MR) angiography now allow accurate depiction of the carotid arteries that may be adequate for surgical planning in many cases. This report examines the accuracy of MR angiography compared with that of conventional angiography in symptomatic patients undergoing carotid endarterectomy and compares them with surgical findings. Twenty-one carotid arteries in 20 patients were treated surgically for severe stenosis or occlusion. Preoperatively, all patients had both MR and conventional angiograms, which were interpreted on a five-grade scale by two independent neuroradiologists who were unaware of the patient's clinical history. The two studies were highly correlated, particularly in the case of severe stenosis and occlusion. There were no false-negative MR studies that missed surgically significant lesions. In two cases, MR angiography overestimated the stenosis by one grade. On MR angiography, surgically significant stenosis appears as focal areas of signal intensity loss at the level of stenosis with reappearance of the signal distally. If the distal signal intensity does not reappear, the artery is likely to be occluded. In symptomatic patients, MR angiograms that demonstrate a flow-void gap with distal reappearance at a site consistent with the symptoms may be adequate as the sole preoperative study. Three patients who underwent carotid endarterectomy on this basis are presented. The factors that contribute to artifactual and overestimated stenosis are reviewed.
Aged↗
Intracranial pressure reduction by a central alpha-2 adrenoreceptor agonist after subarachnoid hemorrhage.
Pharmacological manipulation of cerebral venous blood volume is a theoretical approach to reduce elevated intracranial pressure (ICP). Microapplication of alpha-2 adrenoreceptor agonists has been shown to constrict pial veins selectively. This report explores the physiological effects of the intravenous alpha-2 agonist xylazine in a canine model of raised ICP after subarachnoid hemorrhage (mean arterial pressure, heart rate, and ICP were measured and compared in five groups: normal saline [n = 4], xylazine [0.05-1.00 mg/kg] [n = 28], tolazoline [a semiselective alpha-2 antagonist, 5 mg/kg] [n = 6], tolazoline [5 mg/kg] plus xylazine [1.0 mg/kg] [n = 7], and phenylephrine [0.008 mg/kg], a selective alpha-1 agonist [n = 3]). Treatment with xylazine produced a significant (P < 0.01), transient, dose-dependent reduction in ICP that was blocked by pretreatment with tolazoline. Treatment with tolazoline alone produced significant (P < 0.01) increases in ICP and mean arterial pressure. Treatment with phenylephrine produced significant (P < 0.01) increases in mean arterial pressure but had no affect on ICP. These results raise the possibility of using an alpha-2 adrenoreceptor agonist for the treatment of elevated ICP after brain injury.
Animals↗
Pressure autoregulation is intact after arteriovenous malformation resection.
Explore the source record for details and available documents.
Blood Pressure↗
Endarterectomy of the intradural vertebral artery via the far lateral approach.
Transient ischemic attacks (TIAs) of the posterior circulation are associated with a significant risk of subsequent infarction, particularly when caused by stenotic lesions in the intracranial portion of the vertebral artery (VA). Eight patients who had persistent posterior circulation TIAs despite receiving maximal medical therapy (including anticoagulation) and who had angiographic evidence of severe stenosis of the proximal intracranial VA with poor collateral flow were treated by endarterectomy of the intradural VA. Their ages ranged from 52 to 65 years. Five of these operations were performed via the far lateral approach. In all patients, the contralateral VA was hypoplastic or occluded, or ended in the posterior inferior cerebellar artery. Postoperative angiograms showed that the arteries of five of the patients were widely patent, one was improved but still stenotic, and two were occluded. The latter two patients subsequently underwent thrombectomy, after which the artery was patent in one patient and remained occluded in the other. After surgery, the TIAs of seven patients were relieved completely, and the patients were neurologically intact. The patient with persistent occlusion ultimately had moderate disability. Complications included the two cases of thrombotic occlusion that required a second operation, three cases of communicating hydrocephalus that required lumboperitoneal shunts, and two cases of transient dysfunction of the 9th and 10th cranial nerves. Suitable patients with persistent posterior circulation TIAs refractory to medical therapy who have appropriate angiographic evidence of proximal VA stenosis and poor collateral flow may benefit from endarterectomy of the intradural VA.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Surgical resection of intramedullary spinal cord cavernous malformations.
Cavernous malformations are being increasingly well recognized throughout the central nervous system, where they compose approximately 1% of all vascular lesions and 15% of all vascular malformations. These malformations are uncommon in the spinal column and rarely found within the spinal cord. There have been only a few isolated reports of surgical resection of intramedullary spinal cord cavernous malformations. A series of six patients with intramedullary spinal cord cavernous malformations is described; all were treated by complete surgical excision, and all had a good or excellent outcome with partial or complete relief of neurological symptoms. There were no surgical complications, although transient postoperative neurological worsening was common. The clinical, radiological, and surgical features of these patients are discussed. It is concluded that intramedullary spinal cord cavernous malformations are an uncommon cause of progressive myelopathy that can be safely and effectively treated by surgical excision.
Adolescent↗
Improved transdural exposure and temporary occlusion of the petrous internal carotid artery for cavernous sinus surgery. Technical note.
Safe surgery for vascular and neoplastic lesions involving the cavernous sinus requires adequate proximal control of the cavernous internal carotid artery (ICA). Classically, control of the cavernous ICA has necessitated dissection and isolation of the cervical vessels. The authors describe an alternative method for obtaining vascular control via transdural exposure of the petrous ICA and the use of the Fogarty balloon embolectomy catheter inserted extra-arterially into the carotid canal to provide temporary occlusion. This method is particularly well suited for proximal ICA occlusion during short-segment petrous-to-paraclinoid ICA bypass procedures as it eliminates the need for a temporary proximal ICA aneurysm clip and increases the available working space for completion of the anastomosis.
Carotid Artery, Internal↗
Giant serpentine middle cerebral artery aneurysm treated by extracranial-intracranial bypass. Case report.
Giant intracranial aneurysms often pose difficult management issues. Such aneurysms may not be amenable to direct surgical attack because of their size, location, or lack of a clear aneurysmal neck. In such cases, a combination of strategies may provide a means of proximal aneurysm occlusion and distal cerebral revascularization. The authors report the successful treatment of a giant (186.8-ml) serpentine aneurysm of the left middle cerebral artery (MCA) in a 14-year-old boy. The aneurysm was managed in a two-stage procedure in which the MCA branches distal to the aneurysm were anastomosed first with branches of the left superficial temporal artery. After the bypass procedure, direct occlusion of the MCA was performed at the proximal base of the aneurysm at its site of dilatation. The patient had no intraoperative or postoperative complications and was intact neurologically 6 months following the procedures.
Adolescent↗
Preservation of olfaction in anterior craniofacial approaches.
Through the combined efforts of neurosurgeons, head and neck surgeons, and craniofacial surgeons, the standard transbasal approach to the frontal fossa has been modified to include removal of the orbital roofs, nasion, and ethmoid sinuses. This approach has been combined further with facial disassembly procedures to provide extensive midline exposure to the midface and clival region. Extended frontal approaches, however, necessitate removal of the crista galli and sectioning of the olfactory rootlets with the associated risk of anosmia, cerebrospinal fluid (CSF) leak, and the need for complex reconstruction of the frontal floor. To avoid these problems, the authors have modified the technique of handling the cribriform plate to preserve the olfactory unit. Circumferential osteotomy cuts are made around the cribriform plate to allow an en bloc removal with its attachment to both the dura and underlying mucosa. Opening of the dura is avoided and the cribriform bone is used to reconstruct the floor. Four patients underwent this approach, for treatment of an angiofibroma in three and a fibrosarcoma in one. The mean follow-up period was 7 months. No patients developed a CSF leak, and within 8 weeks olfaction had returned in all patients. There was no other associated morbidity. These data suggest that this modification of the transbasilar approach can alleviate extensive reconstructive procedures and CSF leaks while preserving olfaction.
Adolescent↗
Cervical-to-petrous internal carotid artery bypass procedure. Technical note.
The technique for cervical-to-petrous internal carotid artery saphenous vein bypass is described. This procedure was used in the treatment of three patients with high cervical or skull base vascular injuries. All grafts were patent on follow-up angiography.
Carotid Artery Diseases↗
Carotid endarterectomy complicated by vein patch rupture.
Explore the source record for details and available documents.
Blood Vessel Prosthesis↗
The combined supra- and infratentorial approach for lesions of the petrous and clival regions: experience with 46 cases.
The combined supra- and infratentorial approach has been subdivided into three variations: the retrolabyrinthine technique (petrous bone resection with preservation of hearing); the translabyrinthine technique (greater petrous bone resection and sacrifice of hearing); and the transcochlear technique (maximum petrous drilling, sacrifice of hearing, and transposition of the facial nerve). These three variations maximize temporal bone drilling and therefore provide exquisite exposure of the clivus and petrous regions with minimal or no brain retraction. The superior petrosal sinus is always sacrificed and the tentorium completely cut. The sigmoid sinus can be transected or kept intact, depending on the venous drainage and the degree of exposure required. A series of 46 patients who underwent the combined approach is presented.
Adult↗
Thromboendarterectomy of the symptomatic occluded internal carotid artery.
A retrospective review of 42 patients (mean age 61.4 years) with surgically managed symptomatic internal carotid artery occlusion is reported. A standardized surgical protocol aimed at restoration of flow in the vessel was used. Presenting symptoms included hemispheric transient ischemic attacks in 68% of patients, new fixed neurological deficits in 28%, amaurosis fugax in 28%, and stroke-in-evolution in 9%. Twenty-four arteries were successfully reopened. A proximal remnant angioplasty (stumpectomy) was performed alone in nine patients or in combination with an external carotid endarterectomy in nine. In four patients with persisting symptoms who failed to achieve primary restoration of flow, a superficial temporal-to-middle cerebral artery bypass procedure was performed. The permanent surgical morbidity rate was 2% and the surgical mortality rate was 0%. Transient postoperative deficits were present in three patients (7%). Follow-up review at a mean of 40 months was obtained in 39 patients (93%). Following surgical intervention, five patients died of unrelated causes, two had neurological events consistent with a transient cerebral ischemic attack, and two had vertebrobasilar insufficiency. No patient suffered from stroke. Of the 24 successfully reopened vessels, follow-up ultrasound evaluations were obtained in 17 (73%) at a mean of 28 months after surgery. In 15 patients (88%) the vessels were widely patent, one (5.8%) had stenosis greater than 70%, and one (5.8%) showed asymptomatic reocclusion. Reopening occluded internal carotid arteries in selected patients is associated with low surgical morbidity and mortality rates. Further studies are necessary to determine the impact of this surgical therapy on the natural history of this condition.
Algorithms↗
Anastomosis of the anterior temporal artery to a secondary trunk of the middle cerebral artery for treatment of a giant M1 segment aneurysm. Case report.
The clinical course, operative technique, and angiographic outcome are reported for a patient with a giant intracranial aneurysm of the proximal middle cerebral artery (MCA) who presented with symptoms of ischemia. Treatment of the aneurysm required bypassing the involved MCA bifurcation, but the patient lacked a suitable donor superficial temporal artery. The involved arterial segment was therefore bypassed with a side-to-side anastomosis of the anterior temporal artery to one of the secondary trunks of the MCA. This bypass eliminated the need to harvest a vein graft and re-established flow using in situ intracranial vessels of similar diameter, minimal arterial dissection, and only one suture line.
Adolescent↗