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Biomedical subjects

Robert F Spetzler

Publications and source records attributed to Robert F Spetzler.

At least 73 records · Page 4Linked to original sources
PubMed2005

Cavernous malformation of the trigeminal nerve manifesting with trigeminal neuralgia: case report.

OBJECTIVE AND IMPORTANCE: We describe a patient with a cavernous malformation within the trigeminal nerve at the nerve root entry zone who presented with trigeminal neuralgia. CLINICAL PRESENTATION: A 52-year-old woman sought treatment after experiencing dizziness and lancinating left facial pain for almost a year. Neurological examination revealed diminished sensation in the distribution of the trigeminal nerve on the left. Magnetic resonance imaging demonstrated a minimally enhancing lesion affecting the trigeminal nerve. INTERVENTION: The patient underwent a retrosigmoid craniotomy. At the nerve root entry zone, the trigeminal nerve was edematous with hemosiderin staining. The lesion, which was resected with microsurgical technique, had the appearance of a cavernous malformation on gross and histological examination. The patient's pain improved significantly after resection. CONCLUSION: Cavernous malformations can afflict the trigeminal nerve and cause trigeminal neuralgia. Microsurgical excision can be performed safely and is associated with improvement in symptoms.

Cranial Nerve Neoplasms↗
PubMed2005

Incidence of superficial sylvian vein compromise and postoperative effects on CT imaging after surgical clipping of middle cerebral artery aneurysms.

BACKGROUND AND PURPOSE: Dissection and retraction of the sylvian fissure can cause venous insufficiency and may be an important contributor to postoperative edema or hemorrhage after clipping of a middle cerebral artery (MCA) aneurysm. The incidence of changes in the superficial middle cerebral vein (SMCV) and adjacent veins and whether such changes increase the amount of edema or hemorrhage on postoperative CT is the focus of this study. METHODS: Pre- and postoperative angiograms of 100 consecutive patients with MCA aneurysms treated by craniotomy and clipping were compared to determine the postoperative incidence of changes involving the SMCV. CTs from the normal and abnormal postoperative venous groups were compared to determine the amount of edema or presence of parenchymal hemorrhage. RESULTS: Postoperatively, 31 (31%) SMCVs were altered, 20 to a minor or moderate degree. Eleven cases were pronounced. In 9 (9%) cases, the SMCV was completely obscured or failed to fill on postoperative angiography. More edema (observer 1, P < .0002; observer 2, P < .0006) and small brain parenchymal hemorrhages (observer 1, P < .00003; observer 2, P < .00001) were found on the postoperative CT images of the group whose SMCVs were altered than those that were unchanged. CONCLUSIONS: Neurosurgeons and neuroradiologists should be attentive to changes in the SMCV and adjacent venous structures to optimize outcomes of procedures involving the sylvian fissure.

Brain Edema↗
PubMed2005

Subarachnoid hemorrhage due to isolated spinal artery aneurysm in four patients.

Spinal artery aneurysms are usually found with arteriovenous malformations or other entities that increase hemodynamic stress. Isolated spinal artery aneurysms are rare. Four patients who presented with the acute onset of lower back pain underwent MR imaging, which revealed spinal subarachnoid hemorrhage. In all patients, work-up yielded a diagnosis of isolated spinal aneurysm, and operative treatment was successful. In the appropriate clinical setting, spinal aneurysm should be considered as a possible cause of spinal subarachnoid hemorrhage.

Adult↗
PubMed2004

Combined endovascular and microsurgical management of giant and complex unruptured aneurysms.

OBJECT: The purpose of this study was to assess the efficacy and describe the technical features of combined endovascular and microsurgical treatments for complex and giant unruptured intracranial aneurysms. METHODS: A prospectively maintained database was reviewed to identify all patients with unruptured intracranial aneurysms who were treated with combined techniques. Twenty-one lesions were treated in as many patients: six lesions involved the posterior cerebral artery (PCA); seven the cavernous portion of the internal carotid artery (ICA); two the basilar apex; two the basilar trunk; and one each the anterior communicating artery, anterior cerebral artery, petrous ICA, and cervical ICA. Aneurysms were treated with combined extracranial-intracranial bypass procedures and parent-vessel occlusion, flow redirection, or arterial transposition. Aneurysm occlusion was achieved in 20 patients. In the remaining patient the aneurysm recurred, requiring stent-assisted repeated coil placement. Three patients suffered permanent neurological deficits related to treatment, and three died, two of whom had basilar trunk aneurysms. CONCLUSIONS: Certain complex aneurysms may be treated optimally by combining endovascular and surgical procedures. A low incidence of complications follows treatment of anterior circulation aneurysms. Treatment of complex posterior circulation aneurysms is associated with a higher incidence of complications, although this likely reflects the more complex nature of these lesions. The risks of this combined treatment strategy are likely lower than the risks associated with the natural history of this subset of aneurysms.

Adult↗
PubMed2004

Anterior communicating artery aneurysm following radiation therapy for optic glioma: report of a case and review of the literature.

A 42-year-old female presented with subarachnoid hemorrhage (SAH), presumably from a radiation-induced anterior communicating artery aneurysm. Six years earlier, she had undergone radiation treatment for an optic glioma that was diagnosed based on imaging criteria. The aneurysm was successfully clipped, and the optic glioma was biopsied to verify the diagnosis histologically. Radiation-induced cerebral aneurysms often manifest with a fatal SAH. These aneurysms typically develop in the field of radiation and are diagnosed a mean of 8.52 years after radiation. Rarely, the aneurysm sac thromboses spontaneously. Clipping or coiling of the aneurysm can be an effective treatment.

Case Reports↗
PubMed2004

Intraoperative Iso-C C-arm navigation in craniospinal surgery: the first 60 cases.

OBJECTIVE: The intraoperative Iso-C C-arm (Siremobil Iso-C 3D; Siemens Medical Solutions, Erlangen, Germany) provides a unique ability to acquire and view multiplanar three-dimensional images of intraoperative anatomy. Registration for intraoperative surgical navigation may be automated, thus simplifying the operative workflow. METHODS: Iso-C C-arm intraoperative fluoroscopy acquires 100 images, each of which must be 1.8 degrees in a circumferential fashion about an "isocentric" point in space. The system generates a high-resolution isotropic three-dimensional data set that is available immediately after the 90-second C-arm rotation. The data set is ported to the image-guided workstation, registration is immediate and automated, and the surgeon can navigate with millimetric accuracy. The authors prospectively examined data from the initial 60 patients examined with the Iso-C, among whom were cases of anterior and posterior spinal instrumentation from the occiput to the sacrum. Percutaneous and minimally invasive spinal and cranial procedures were also included. RESULTS: Automated registration for image-guided navigation was attainable for anterior and posterior cases from the cranial base and entire spine. In most cases, intraoperative postprocedural imaging with the Iso-C mitigated the need for postoperative imaging. CONCLUSION: Intraoperative Iso-C three-dimensional scanning allows real-time feedback during cranial base and spinal surgery and during procedures involving instrumentation. In most cases, it obviates the need for postoperative computed tomography. Its usefulness is in its simplicity, and it can be easily adapted to the operating room workflow. When coupled with intraoperative navigation, this new technology facilitates complex neurosurgical procedures by improving the accuracy, safety, and time of surgery.

Adolescent↗
PubMed2004

Diagnosis and management of pineocytomas.

OBJECTIVE: Pineocytomas are associated with the most favorable prognosis of all pineal tumors. However, a subset of pineocytomas may have a predilection for recurrence and therefore behave aggressively. PATIENTS AND METHODS: Records of nine patients (five men, four women; mean age, 44 yr; range, 24-63 yr) with histologically diagnosed pineocytomas consecutively treated between 1990 and 2003 were reviewed retrospectively to identify factors predictive of aggressiveness. Eight patients presented with hydrocephalus and four with tectal compression. Three patients underwent gross total resection, and six underwent subtotal resection or biopsy. RESULTS: Three local recurrences necessitated reoperation. One recurrence involved the obex of the fourth ventricle. The mean time to recurrence was 3.5 years (range, 1-7 yr). There was no correlation between histological features and tumor recurrence. Patients undergoing radiosurgery showed stable or attenuated local disease (mean follow-up, 19.3 mo; range, 6-36 mo). Mean radiographic follow-up was 34 months (range, 6 mo to 10 yr). Mean clinical follow-up was 36 months (range, 1 mo to 10 yr). CONCLUSION: A subset of pineocytomas demonstrates the potential for symptomatic recurrence. We advocate an attempt at gross total tumor resection for all symptomatic patients with tectal plate compression, reserving radiosurgery for small, subtotally resected, or recurrent lesions. Patients must be followed closely for recurrence. Radiosurgery seems to be beneficial for local tumor control. Further investigation is needed to identify histological markers for pineocytomas that behave aggressively.

Adult↗
PubMed2004

Superficial temporal artery-to-middle cerebral artery bypass grafting for cerebral revascularization.

Superficial temporal artery-to-middle cerebral artery bypass procedures are an important tool in the armamentarium of cerebrovascular surgeons for the treatment of carotid occlusion and revascularization for complex aneurysms and brain tumors. This article enumerates the essential steps in performing superficial temporal artery-to-middle cerebral artery bypass procedures. The nuances of this technique reflect the extensive experience of the senior authors.

Anastomosis, Surgical↗
PubMed2004

Anteroinferior cerebellar artery aneurysms: surgical approaches and outcomes--a review of 34 cases.

OBJECTIVE: Anteroinferior cerebellar artery (AICA) aneurysms are rare lesions whose treatment requires expertise in vascular, endovascular, and cranial base surgery. This article presents the largest series treated at one center. METHODS: We retrospectively analyzed presenting symptoms, aneurysm characteristics, surgical approaches, postoperative outcomes, and the application of endovascular techniques. RESULTS: We found 32 patients with 34 AICA aneurysms (11 men and 21 women; age range, 6-77 yr; mean age, 51 yr). Twenty-one aneurysms had ruptured; 13 were unruptured. Seven of the unruptured aneurysms presented with brainstem compression, and six were found incidentally. Surgical approaches included the retrosigmoid, far-lateral transcochlear, translabyrinthine, and orbitozygomatic. Eighteen patients (56%) had neurological complications. Thirty aneurysms were at proximal locations, and four were distal. Intraoperative hypothermic cardiac arrest was used to clip eight giant aneurysms. Follow-up was available in 56% of the patients for a mean of 41 months. The mean Glasgow Outcome Scale scores at discharge were not significantly different from the patients' status at their initial assessment. CONCLUSION: We recommend the standard retrosigmoid approach for treating small to medium aneurysms involving the lower two-thirds of the clivus or distal AICA aneurysms. Cranial base approaches are recommended for large or giant aneurysms or for those proximal to the emergence of the AICA from the basilar trunk. Hypothermic cardiac arrest facilitates dissection of giant aneurysms. Endovascular treatment is a useful adjunct for treating residual aneurysms but did not provide definitive treatment in any of our patients.

Adolescent↗
PubMed2004

Comparison of rapid and gradual weaning from external ventricular drainage in patients with aneurysmal subarachnoid hemorrhage: a prospective randomized trial.

OBJECT: The goal of this study was to compare rapid and gradual weaning from external ventricular drainage in patients with aneurysmal subarachnoid hemorrhage (SAH) in a prospective, randomized trial. METHODS: Between December 2001 and December 2002, 81 patients with aneurysmal SAH in whom external ventricular drains (EVDs) had been placed were enrolled in the study: 41 patients were randomized to the rapidly weaned group and 40 were randomized to the gradually weaned group. The two groups were well matched with respect to age, sex, posterior aneurysm location, Fisher grade, Hunt and Hess grade, intraventricular hemorrhage on admission, and hydrocephalus on admission. Rapid weaning was defined as weaning that occurred within 24 hours with immediate closure of the EVD, whereas gradual weaning took place over a 96-hour period with daily, sequential height elevations of the EVD system followed by drain closure for 24 hours. All patients in whom EVD weaning failed underwent shunt placement. Rates of shunt implantation, days in the intensive care unit (ICU), and overall duration of hospitalization were compared. There was no significant difference in rates of shunt implantation between the rapidly weaned (63.4%) and gradually weaned (62.5%) groups. Nevertheless, patients in the gradually weaned group spent a mean of 2.8 more days in the ICU (p = 0.0002) and 2.4 more days in the hospital (p = 0.0314) than patients in the rapidly weaned group. CONCLUSIONS: Compared with rapid weaning, gradual, multistep EVD weaning provided no advantage to patients with aneurysmal SAH in preventing the need for long-term shunt placement and prolonged ICU and hospital stays.

Adult↗
PubMed2004

Comparison of routine and selective use of intraoperative angiography during aneurysm surgery: a prospective assessment.

OBJECT: Whether routine intraoperative angiography is necessary for cerebral aneurysm surgery is currently under debate. In this study the authors prospectively assessed the cerebrovascular surgeon's accuracy in predicting the need for intraoperative angiography. METHODS: Between January 2002 and January 2003, 200 consecutive patients (141 female and 59 male patients, mean age 52.8 years) with 235 aneurysms underwent routine intraoperative angiography. Before the operation, the surgeons indicated whether they believed that intraoperative angiography was necessary. Their responses were recorded as "intraoperative angiography necessary" or "intraoperative angiography unnecessary." Regardless of the response, all patients underwent intraoperative angiography after the aneurysm had been clipped. Changes in treatment resulting from intraoperative angiography were compared with surgeons' preoperative predictions of the need for intraoperative angiography. Intraoperative angiography was predicted to be necessary in 41 cases (20%) and unnecessary in 159 cases (80%). Its use altered treatment in 14 patients. Seven of these patients were among the group in which intraoperative angiography was deemed necessary and seven were in the group in which it was considered unnecessary. In the latter group, two patients had residual aneurysms, three had parent vessel occlusion, and two had previously undiagnosed aneurysms. Only one patient (0.5%) sustained a major intraoperative complication attributed to angiography. CONCLUSIONS: Given the frequency of significant disease that remains undetected if intraoperative angiography is used on a selective basis and the low complication rate associated with the procedure, the use of intraoperative angiography should be considered in the majority of aneurysm cases.

Adolescent↗
PubMed2004

Intraoperative stereoscopic QuickTime Virtual Reality.

OBJECT: The aim of this study was to acquire intraoperative images during neurosurgical procedures for later reconstruction into a stereoscopic image system (QuickTime Virtual Reality [QTVR]) that would improve visualization of complex neurosurgical procedures. METHODS: A robotic microscope and digital cameras were used to acquire left and right image pairs during cranial surgery; a grid system facilitated image acquisition with the microscope. The surgeon determined a field of interest and a target or pivot point for image acquisition. Images were processed with commercially available software and hardware. Two-dimensional (2D) or interlaced left and right 2D images were reconstructed into a standard or stereoscopic QTVR format. Standard QTVR images were produced if stereoscopy was not needed. Intraoperative image sequences of regions of interest were captured in six patients. Relatively wide and deep dissections afford an opportunity for excellent QTVR production. Narrow or restricted surgical corridors can be reconstructed into the stereoscopic QTVR mode by using a keyhole mode of image acquisition. The stereoscopic effect is unimpressive with shallow or cortical surface dissections, which can be reconstructed into standard QTVR images. CONCLUSIONS: The QTVR system depicts multiple views of the same anatomy from different angles. By tilting, panning, or rotating the reconstructed images, the user can view a virtual three-dimensional tour of a neurosurgical dissection, with images acquired intraoperatively. The stereoscopic QTVR format provides depth to the montage. The system recreates the dissection environment almost completely and provides a superior anatomical frame of reference compared with the images captured by still or video photography in the operating room.

Brain↗
PubMed2004

Moyamoya.

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Adolescent↗
PubMed2003

Salvage of advanced squamous cell carcinomas of the head and neck: internal carotid artery sacrifice and extracranial-intracranial revascularization.

OBJECT: Squamous cell carcinoma (SCC) of the head and neck may involve the carotid artery (CA) in the neck or skull base. Whether tumor resection should be associated with sacrifice of the CA is debatable. METHODS: Records obtained in five consecutive patients (three men, and two women; mean age 58 years, range 47-69 years) treated for recurrent or progressive SCC involving the internal carotid artery (ICA) at the skull base were reviewed retrospectively. The ICA was sacrificed, an extracranial-intracranial (EC-IC) bypass was performed using a saphenous vein graft, and the tumor and involved ICA segment were resected. Gross-total resection of the SCC was achieved in four cases. One patient died of an acute postoperative stroke due to bypass occlusion and did not undergo tumor resection. No other permanent ischemic or neurological deficits were noted. The other four patients died of tumor progression (survival range 2-40 months, mean 14 months). One patient survived for more than 2 years (2-year overall survival rate 20%). Histological tumor invasion of the CA wall was verified in one of the three evaluated specimens. CONCLUSIONS: A high rate of morbidity and mortality is associated with cases in which skull base CA sacrifice and an EC-IC bypass are performed. Not all resected arteries are shown to have malignant infiltration on histological examination. Better preoperative imaging criteria are needed to define malignant infiltration of the ICA at the skull base. Chemotherapy and radiotherapy without aggressive tumor resection may be an option for these patients.

Aged↗
PubMed2003

Pineal region lesion masquerading choroid plexus papilloma: case report.

BACKGROUND: Choroid plexus papillomas (CPPs) are rare intracranial neoplasms, especially in the third ventricle. We report a patient with a posterior third ventricular CPP extending into the pineal that radiographically and clinically presented as a pineal region lesion. CASE DESCRIPTION: In a 51-year-old female with headache and upward gaze impairment radiological examination showed a mass in the pineal region obstructing the aqueduct of Sylvius and causing hydrocephalus. After ventriculoperitoneal shunting the tumor was approached through the infratentorial-supracerebellar approach and pathological examination revealed a typical CPP. CONCLUSIONS: This case represents an unusual presentation of an intracranial CPP. This entity should be considered an extremely rare cause of a lesion in the pineal region.

Diagnosis, Differential↗
PubMed2003

Posttreatment imaging of the skull base.

Imaging the skull base after surgery can be challenging because anatomic structures may have been destroyed by an underlying process or removed at surgery. Foreign substances may be introduced to fill a void left by tumor resection, for hemostasis, and to repair dural defects. Previous imaging studies must be available for comparison to understand the characteristics of an underlying lesion. By following the progression of a lesion on subsequent imaging studies, the nature of treatment-related changes and residual or recurrent pathology is best realized.

Angiography↗