Biomedical subjects

W R Marsh

Publications and source records attributed to W R Marsh.

At least 19 recordsLinked to original sources

PubMed1998

Acute postoperative seizures following anterior temporal lobectomy for intractable partial epilepsy.

OBJECT: Recurrence of seizures immediately following epilepsy surgery can be emotionally devastating, and raises concerns about the chances of successfully attaining long-term seizure control. The goals of this study were to investigate the frequency of acute postoperative seizures (APOS) occurring in the 1st postoperative week following anterior temporal lobectomy (ATL) to identify potential risk factors and to determine their prognostic significance. METHODS: One hundred sixty consecutive patients who underwent an ATL for intractable nonlesional temporal lobe epilepsy were retrospectively studied. Acute postoperative seizures occurred in 32 patients (20%). None of the following factors were shown to be significantly associated with the occurrence of APOS: age at surgery, duration of epilepsy, side of surgery, extent of neocortical resection, electrocorticography findings, presence of mesial temporal sclerosis, and hippocampal volume measurements (p > 0.05). Patients who suffered from APOS overall had a lower rate of favorable outcome with respect to seizure control at the last follow-up examination than patients without APOS (62.5% compared with 83.6%, p < 0.05). The type of APOS was of prognostic importance, with patients whose APOS were similar to their preoperative habitual seizures having a significantly worse outcome than those whose APOS were auras or were focal motor and/or generalized tonic-clonic seizures (excellent outcome: 14.3%, 77.8%, and 75%, respectively, p < 0.05). Only patients who had APOS similar to preoperative habitual seizures were less likely to have an excellent outcome than patients without APOS (14.3% compared with 75%, p < 0.05). Timing of the APOS and identification of a precipitating factor were of no prognostic importance. CONCLUSIONS: The findings of this study may be useful in counseling patients who suffer from APOS following ATL for temporal lobe epilepsy.

Acute Disease↗

PubMed1996

Complications resulting from saphenous vein patch graft after carotid endarterectomy.

OBJECTIVE: Reducing surgical risks to the minimum in carotid endarterectomy has become crucial, especially with the results of recent clinical trials extending indications to asymptomatic patients. The use of the saphenous vein patch graft (SVPG) has been suggested to reduce early postoperative thrombosis and cerebral infarct as well as late recurrent stenosis. However, the exact risks and complications involved in this technique are not known. METHODS: During a 23-year period (1972-1994), 2888 carotid endarterectomies with SVPG for primary carotid stenosis were performed by the Neurosurgical Cerebrovascular Service at the Mayo Clinic. The data from all patients were retrospectively analyzed, emphasizing postoperative complications related to SVPG. RESULTS: There were five postoperative vein ruptures (0.17%), four cases of aneurysm formation, and three cases of deep infection necessitating surgical intervention. The vein patch ruptured in one male patient and four female patients (mean age, 69 yr). All ruptures occurred within 4 days of the primary operation, including two during the first 24 hours. All patients with rupture underwent emergency surgery and were found to have intact suture lines and tears in the middle of the grafts. Two patients recovered without deficits, one suffered major disability, and the other two died. Aneurysm of the patch developed in two male patients and two female patients (mean age, 71 yr). All of the patients developed painless pulsatile neck masses 1 to 9 years after the initial surgery; two also had recurrent ischemic symptoms. All of the patients with aneurysms underwent surgical correction without consequences. CONCLUSION: Although the benefit of routine use of SVPG in carotid endarterectomy is still the focus of debate, this analysis showed that its use adds a small but definite risk of serious complications related to inherent weakness of the venous tissue. If a surgeon chooses to use a patch graft, our recommendation is for use of a synthetic material rather than vein.

Aged↗

PubMed1996

Traumatic occlusion of one limb of an intracranial arterial fenestration: an uncommon cause of stroke.

Three weeks after an automobile accident, a 35-year-old man experienced left throat and neck pain, numbness of the left face and tongue, dysphagia, left arm pain and weakness, and left miosis. At age 27, he had suffered an aneurysmal subarachnoid hemorrhage. Angiography at that time had also demonstrated a fenestration of the left intracranial vertebral artery. At the time of the second presentation, angiography showed that one of the limbs of the fenestration had become occluded. Although the vast majority of intracranial arterial fenestrations are asymptomatic, occlusion of one of the limbs of a fenestration may be the cause of stroke.

Adult↗

PubMed1996

Diagnosis and management of primary spinal epidural non-Hodgkin's lymphoma.

OBJECTIVE: To describe the diagnosis, management, and outcome in 10 patients with histologically confirmed primary spinal epidural non-Hodgkin's lymphoma. MATERIAL AND METHODS: We review the findings in a cohort of seven men and three women in whom this tumor was diagnosed between January 1979 and January 1993 and discuss the prognostic differences between primary and secondary spinal lymphomas. RESULTS: All patients (median age at diagnosis, 70 years) underwent a decompressive laminectomy, subtotal tumor resection, and spinal irradiation (median dose, 3,800 cGy). Nine of 10 tumors were of B-cell origin. Six patients are alive and well. In four patients, recurrent disease developed from 15 to 62 months after the original diagnosis; of these, one has died. The median duration of survival of all patients was 42 months; of those living more than 24 months after diagnosis, the median duration of survival was 80 months. CONCLUSION: A rapidly progressive spinal cord or cauda equina syndrome with neuroimaging findings consistent with an extradural compressive lesion should alert caregivers to the possibility of spinal epidural lymphoma. Although the prognosis for patients with secondary spinal epidural non-Hodgkin's lymphoma is often poor, primary spinal epidural non-Hodgkin's lymphoma can be associated with a favorable outcome if diagnosed and treated early.

Adult↗

PubMed1995

Intractable frontal lobe epilepsy: pathological and MRI features.

The clinical, pathological, and at least one year follow-up of 48 patients with intractable frontal lobe partial epilepsy who underwent surgical treatment for their seizure disorder were reviewed. The group consisted of 27 males and 21 females. Preoperative magnetic resonance imaging (MRI) was normal (26 patients), demonstrated focal frontal lobe (16 patients) or multilobar signal abnormalities (6 patients). Postoperatively patients were divided into one of four groups based upon the degree of seizure activity (Class I: seizure free, Class IV: little to no improvement, Classes II/III: intermediate). Eight patients with tumors (low grade gliomas) were Class I (N = 6) or Class II (N = 2) postoperatively. The remaining six patients with focal, completely resected pathological lesions (e.g. tubers, contusions, etc.) also had Class I or Class II outcomes. Of the 31 patients with the pathological diagnosis of gliosis, the outcome was dependent on the MRI appearance. Preoperative MRI scans of these patients were normal (N = 23), or had focal frontal lobe (N = 2) or multilobar (N = 6) abnormalities. The gliosis patients with unilateral frontal MRI lesions had a good outcome (Class I or II) while those with multilobar MRI abnormalities were all Class IV. Successful outcome correlated strongly with both focal frontal lobe MRI and pathological abnormalities in contrast to the less favorable results seen in patients with normal head MRI scans and gliosis or no pathological abnormality on pathological examination. Multilobar MRI abnormalities invariably had the poorest outcome of all patient groups. Thus presurgical MRI is an important tool and predictor of surgical outcome in patients with frontal lobe epilepsy.

Epilepsy, Frontal Lobe↗

PubMed1995

Depth electrode studies in temporal lobe epilepsy: relation to quantitative magnetic resonance imaging and operative outcome.

We performed a retrospective study of 30 patients with presumed intractable temporal lobe epilepsy (TLE) who underwent chronic intracranial EEG monitoring (CIEM). Multicontact depth electrodes were stereotactically implanted through the medial occipital lobe into amygdala and hippocampus. All patients had previously undergone extracranial ictal EEG monitoring that proved inadequate to localize the epileptogenic zone. No morbidity was associated with CIEM in the 30 patients. Twenty-five patients were shown to have exclusively or predominantly unilateral temporal lobe seizures, and 5 patients had bitemporal seizures without unilateral predominance; 24 patients subsequently underwent an anterotemporal lobe cortical resection. Twenty-one patients have been followed a minimum of 1 year postoperatively. Nine patients (43%) had a class I outcome (seizure-free, auras only, or provoked seizures), 3 patients (14%) had a class II outcome (> or = 95% seizure reduction), 4 patients (19%) had a class III outcome (> or = 50% seizure reduction); and 5 patients (24%) had a class IV outcome (< 50% seizure reduction or no change). A prolonged interhemispheric propagation time (p < 0.01) and magnetic resonance imaging (MRI)-identified hippocampal atrophy (p < 0.01) correlated with a favorable surgical outcome. Results of this study may prove useful in counseling patients who undergo CIEM before temporal lobe surgery.

Adolescent↗

PubMed1995

Electrocorticography and temporal lobe epilepsy: relationship to quantitative MRI and operative outcome.

We investigated the relationship between electrocorticography (ECoG), quantitative magnetic resonance imaging (MRI), and surgical outcome in 165 patients with intractable nonlesional temporal lobe epilepsy (NLTLE). A standard mesial temporal resection was performed in all patients. Patients with an operative follow-up < 1 year were excluded from the study. The extent of the lateral temporal neocortex resection (LCR) was guided by ECoG and the side of surgery. The extent of the LCR was not predictive of seizure outcome in patients with or without hippocampal formation atrophy (p > 0.5). Patients undergoing a right anterior temporal lobectomy had a larger LCR (p < 0.0001), but the side of surgery was not of predictive value in determining seizure outcome (p > 0.1). The topography of the acute intracranial spikes did not correlate with operative outcome (p > 0.5) and was independent of hippocampal volumetric studies (p > 0.5). The postexcision ECoG was also shown not to be of prognostic importance (p > 0.5). Our results indicates that the extent of the lateral temporal cortical resection and the ECoG findings are not important determinants of surgical outcome in patients with NLTLE.

Adolescent↗

PubMed1995

Intracranial cysts in autosomal dominant polycystic kidney disease.

Autosomal dominant polycystic kidney disease (ADPKD) is a systemic disorder well known for its association with intracranial aneurysms. A series of patients with ADPKD who were screened for the presence of an intracranial aneurysm were reviewed and found to include an unexpectedly high number with intracranial arachnoid cysts. Among 247 patients with ADPKD who underwent magnetic resonance imaging (180 cases) or high-resolution contrast-enhanced computerized tomography (67 cases), there were 151 women and 96 men with a mean age of 44 years. Intracranial arachnoid cysts were found in 20 patients (8.1%) with ADPKD compared to two (0.8%) in a control group without ADPKD matched for age, sex, and method of imaging (p < 0.0001). Multiple intracranial arachnoid cysts were found in two patients. Polycystic liver disease was present in 17 (85.0%) of the 20 patients with intracranial arachnoid cysts compared to 119 (52.4%) of the 227 patients without (p < 0.004). Pineal cysts were found in two patients (0.8%) and choroid plexus cysts were found in three patients (1.2%) but this was not different from the control population. None of the intracranial cysts was symptomatic and none was treated surgically. Intracranial arachnoid cysts are a relatively frequent incidental finding in patients with ADPKD, providing further support for the systemic nature of this disease. In the authors' experience with approximately 1500 patients with ADPKD, no complication has been encountered from an intracranial arachnoid cyst, suggesting that asymptomatic intracranial arachnoid cysts in patients with ADPKD require no treatment.

Adolescent↗

PubMed1995

Epilepsy surgery.

Epilepsy surgery is an important treatment for many patients with seizures refractory to medical therapy. In this article, the background for this surgery is discussed, and the most common operations reviewed. With early diagnosis and successful surgery, many patients can be returned to active and productive lives.

Cerebral Cortex↗

PubMed1994

Mast cell-rich convexity meningioma presenting as chronic subdural hematoma: case report and review of the literature.

A 47-year-old woman with a convexity meningioma presenting as a chronic subdural hematoma is reported. This case is unique in that the symptoms were cyclical and stereotypic. The tumor contained an unusually high number of mast cells. A possible etiologic role of histamine-related vasodilation and tumoral hemorrhage is explored. The relationship between meningioma and subdural hematoma is discussed, and the literature is reviewed.

Brain↗

PubMed1993

Quantitative MRI hippocampal volumes: association with onset and duration of epilepsy, and febrile convulsions in temporal lobectomy patients.

The relationships between preoperatively acquired MRI-based hippocampal volumes (HV), seizure disorder onset and duration, and early childhood febrile convulsions were investigated retrospectively with data from 72 left and 56 right temporal lobectomy patients. Patients with lesional pathology and heterotopic abnormalities were excluded. Age at development of spontaneous seizures unprovoked by an acute illness defined age of seizure disorder onset. Age of onset was subtracted from age at neurosurgery to determine duration. MRI variables included in this study were the right and left HV divided by total intracranial volume (RAHV, LAHV), and the right-left hippocampal difference (DHF). Partial correlations were used to better isolate relationships with onset of recurrent seizures corrected for age at surgery, and age at neurosurgery corrected for age of recurrent seizure onset. Partial correlations between age at neurosurgery and volume were not significant in either group. LAHV (r = 0.42, P < 0.0003) and DHF (r = -0.49, P < 0.0001) were correlated with age of onset in the left lobectomy group. Correlations in the right lobectomy group were not significant. The presence of a febrile convulsion was associated with smaller LAHV (F(1,70) = 10.54, P < 0.002) and larger DHF (F(1,70) = 11.36, P < 0.002) in left temporal lobectomy patients. The presence of a febrile convulsion in the right temporal group was associated with a slightly smaller DHF (F(1,56) = 5.90, P < 0.02), and slightly smaller RAHV (F(1,56) = 4.49, P < 0.04). These data suggest that hippocampal atrophy remains stable over the duration of temporal lobe onset seizure disorders, and is associated with early onset of recurrent seizures in left temporal patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1993

Carotid endarterectomy in patients with contralateral carotid occlusion.

In this study, we assessed the results of carotid endarterectomy in 357 patients with a carotid stenosis and contralateral carotid occlusion. The overall major neurologic morbidity was 0.6%, and the minor morbidity was 1.1%. The causes of four perioperative deaths (1.1%) were myocardial infarction in two patients, ruptured abdominal aortic aneurysm in one, and respiratory complications in one. Therefore, an excellent result was achieved in 97.2% of patients. With occlusion of the carotid artery for the endarterectomy, 165 patients (46%) had appreciable attenuation in intraoperative electroencephalographic findings and a decrease in cerebral blood flow to approximately 10 ml/100 g of brain tissue per min that necessitated placement of a shunt. This high percentage of profound electroencephalographic and blood flow changes during carotid occlusion suggests that the potential for collateral blood flow in this group of patients is minimal. These results demonstrate that a carotid endarterectomy can be performed at low risk in patients with a contralateral carotid occlusion. We advocate annual noninvasive carotid testing for patients with asymptomatic carotid stenosis and contralateral carotid occlusion. If progression of the stenosis is evident, a prophylactic endarterectomy should be considered because these patients may have a higher risk for cerebral infarction than do patients with a unilateral asymptomatic stenosis.

Aged↗

PubMed1993

MRI assessments of hippocampal pathology in extratemporal lesional epilepsy.

We performed a prospective study in 18 patients to determine the extent of MRI-identified hippocampal pathology in patients with intractable partial epilepsy of extratemporal origin. A mesial temporal signal-intensity alteration or hippocampal formation (HF) atrophy, or both, have been shown to be reliable markers of the temporal lobe of seizure origin in patients with mesial temporal sclerosis. All patients subsequently received surgical ablative therapy between 1988 and 1992. During shortterm follow-up, 14 of the 18 patients experienced a significant reduction in seizure tendency, and 12 patients were rendered seizure-free. Qualitative and quantitative (HF volumetry) assessments of HF pathology were performed retrospectively by a blinded investigator. No hippocampal imaging alteration was present in 17 patients. Left HF atrophy was confirmed in one patient with post-traumatic epilepsy who underwent a successful right frontal lobectomy. Morphometric MRI studies rarely identify hippocampal pathology in patients with extratemporal epilepsy.

Adolescent↗

PubMed1993

MRI hippocampal volumes and memory function before and after temporal lobectomy.

We investigated the relationship between preoperative MRI hippocampal volumes and clinical neuropsychological memory test data obtained before and after temporal lobectomy and amygdalohippocampectomy for intractable epilepsy in 44 left (LTL) and 36 right (RTL) temporal lobectomy patients. In LTL patients, the difference (right minus left hippocampal volume) between hippocampal volumes (DHF) was significantly (p < 0.001) correlated (r = 0.61) with postoperative verbal memory change as measured by a delayed memory percent retention score from the Wechsler Memory Scale-Revised, Logical Memory subtest. DHF was also positively associated with postoperative memory for abstract geometric designs in LTL patients (r = 0.49, p < 0.005). Resection of a relatively nonatrophic left hippocampus was associated with poorer verbal and visual memory outcome. In RTL patients, larger right adjusted (for total intracranial volume) hippocampal volume was associated with decline in visual-spatial learning, but not memory, following surgery. MRI hippocampal volume data appear to provide meaningful information in evaluating the risk for memory impairment following temporal lobectomy.

Adult↗

PubMed1993

Neurocognitive efficiency following left temporal lobectomy: standard versus limited resection.

Decreased memory and learning efficiency may follow left temporal lobectomy. Debate exists as to whether the acquired deficit is related to the size of the surgical resection. This study addresses this question by comparing changes in cognitive performance to the extent of resection of both mesial temporal structures and lateral cortex. The authors retrospectively reviewed 47 right-handed patients who underwent left temporal lobectomy for medically intractable seizures. To examine the effects of the extent of mesial resection, the patients were divided into two groups: those with resection at the anterior 1 to 2 cm of mesial structures versus those with resection greater than 2 cm. To examine the effects of the extent of lateral cortical resection, patients were again divided into two groups: those with lateral cortex resections of 4 cm or less versus those with resections greater than 4 cm. Statistical analyses showed no difference in cognitive outcome between the groups defined by the extent of mesial resection. Likewise, no difference in cognitive outcome was seen between the groups defined by the extent of lateral cortical resection. Associated data analyses did, however, reveal a negative correlation of cognitive change with patient age at seizure onset. These results showed that the neurocognitive consequences of extended mesial resections were similar to those of limited mesial resections, and that the neurocognitive consequences of extended lateral cortical resections were similar to those of limited lateral cortical resections. The risk of cognitive impairment depends more on age at seizure onset than on the extent of mesial or lateral resection.

Adult↗

PubMed1992

Magnetic resonance image-based hippocampal volumetry: correlation with outcome after temporal lobectomy.

We developed a magnetic resonance imaging (MRI)-based technique for measuring the volume of the hippocampal formation. In this study, the relationship between volumes of the hippocampal formation and outcome (i.e., postoperative seizure control) after anterior temporal lobectomy for intractable epilepsy was analyzed in 50 consecutive patients in whom the surgical specimen did not contain an epileptogenic mass lesion. Outcome was classified as either satisfactory or unsatisfactory. A significant relationship was found between outcome and volume of the operated hippocampal formation (p = 0.012), as well as a derived volumetric measure (nonoperated minus operated volume of the hippocampal formation) (p = 0.004). The association between outcome and nonoperated volume was borderline (p = 0.057). Thirty-four (97%) of 35 patients in whom the volumetric study and electroencephalography (EEG) concordantly lateralized the seizure disorder had satisfactory postoperative seizure control. Conversely, only 7 (42%) of 12 patients in whom the volume study was nonlateralizing and 1 (33%) of 3 in whom the EEG and volume study were discordant has a satisfactory outcome. We regard our MRI-based study of hippocampal formation volume as a noninvasive surrogate for the identification of moderate or severe mesial temporal sclerosis. The technique is a useful adjunct in a multidisciplinary, preoperative epilepsy evaluation when T2-weighted MRIs do not reveal an epileptogenic mass lesion. The reasons for the usefulness of this imaging technique are: (1) It is an independent source of information on seizure lateralization, (2) it will provide information as to expected postoperative outcome, and (3) it may aid in appropriately selecting patients for invasive preoperative monitoring studies.

Adult↗

PubMed1992

MRI in the presurgical evaluation of patients with frontal lobe epilepsy and children with temporal lobe epilepsy: pathologic correlation and prognostic importance.

We performed magnetic resonance imaging (MRI) using a high-field strength magnet (1.5 T) in two series of 53 patients with intractable partial epilepsy of frontal lobe or temporal lobe origin who subsequently received ablative surgery for their seizure disorder. In the first series of patients the pathologic correlation and prognostic importance of an MRI-identified lesion in the frontal lobe were assessed. Twenty-five percent of the patients with negative MRI studies and 67% of patients with neuroimaging abnormalities restricted to the frontal lobe, were seizure-free at a minimum duration of follow-up of 1 year. None of the patients with a multilobar MRI-detected abnormality was seizure-free postoperatively. In the second study the sensitivity and specificity of MRI-based hippocampal volumetry was determined in pediatric patients with partial epilepsy of temporal lobe origin unrelated to foreign-tissue pathology. Hippocampal formation atrophy in the epileptic temporal lobe was identified in 63% of patients. The sensitivity and specificity of hippocampal volumetry was 100% in patients with mesial temporal sclerosis. The presence of an MRI-detected epileptogenic lesion in the frontal lobe and hippocampal formation atrophy in the temporal lobe may correlate with the underlying pathology and affect the identification of potential candidates for epilepsy surgery.

Adolescent↗

PubMed1992

Primary spinal epidural non-Hodgkin's lymphoma: report of eight patients and review of the literature.

Eight patients treated for histologically confirmed primary spinal epidural non-Hodgkin's lymphoma diagnosed between January 1979 and August 1989 (6.6% of all cases of intraspinal lymphoma) were studied. There were six men and two women. The median age was 70 years (range, 43-80 yr). Patients sought treatment for a prodrome of back pain (median duration, 3 mo) followed by an acute neurological deterioration (median duration, 6 d). The most common findings were a discrete sensory level in 5 patients, hyperreflexia in 5 patients, and paraparesis or paraplegia in 5 patients. Radiographically, there was an absence of bony destruction by these tumors. All patients underwent a decompressive laminectomy, subtotal tumor resection, and spinal irradiation (median dose, 3800 cGy). Two patients had low-grade lymphomas (one B cell and one T cell), and 6 patients had intermediate-grade lesions (six B cell). Two patients with B-cell lymphomas (one low-grade and one intermediate-grade) developed metastatic disease 15 and 17 months after the initial diagnosis; no evidence of lymphoma developed in the other 6 patients. The median survival was 22 months (range, 2-71 mo). Lymphoma was the cause of death in only 1 of the 4 patients who died, and the 4 younger patients are alive and well. Primary spinal epidural non-Hodgkin's lymphoma should be a diagnostic consideration in the older patient who seeks treatment for spinal cord compression manifested by a prodrome of back pain, followed by a rapid neurological deterioration, normal plain spine radiographs, and neuroimaging consistent with an extradural compressive lesion. Surgery for this diagnosis followed by spinal irradiation should result in significant neurological improvement.

Adult↗