Chronic myelopathy due to a giant spinal arachnoid cyst: a complication of the intrathecal injection of phenol. Case report.

Acquired intradural arachnoid cystic lesions of the spine have been associated with trauma, hemorrhage, parasitic infections, and other insults that cause inflammation and subarachnoid adhesions. The authors describe the case of a previously healthy 36-year-old woman who presented with a chronic myelopathy due to the progressive development of a giant spinal arachnoid cyst that resulted after the intrathecal injection of phenol for the management of chronic upper extremity pain. Neurological examination, spinal computed tomography, and magnetic resonance imaging were used for diagnostic and follow-up purposes.

Optimal treatment of carotid artery disease.

Extracranial carotid artery disease accounts for approximately 25% of ischemic strokes. Although carotid endarterectomy (CEA) is the established gold standard for carotid revascularization, carotid artery angioplasty and stenting (CAS) is continually developing into a safer and more efficacious method of stroke prevention. Embolic protection, improving stent designs, and ever-increasing surgeon experience are propelling CAS towards equipoise with and possible superiority to CEA.

Guidelines for the surgical treatment of unruptured intracranial aneurysms: the first annual J. Lawrence pool memorial research symposium--controversies in the management of cerebral aneurysms.

The management of unruptured cerebral aneurysms remains one of the most controversial topics in neurosurgery. To this end, we discuss the diagnosis and estimated prevalence of these lesions as well as review the literature regarding the rate of rupture for cerebral aneurysms and risks of operative intervention. Our interpretation of the literature concludes that aneurysms are present in approximately 1% of the adult population, varying between less than 1% in young adults to 4% in the elderly.

The impact of microsurgical fenestration of the lamina terminalis on shunt-dependent hydrocephalus and vasospasm after aneurysmal subarachnoid hemorrhage.

Objective: Chronic hydrocephalus requiring shunt placement and cerebral vasospasm are common complications after aneurysmal subarachnoid hemorrhage. Recent publications have investigated the possibility that microsurgical fenestration of the lamina terminalis during aneurysm surgery may reduce the incidence of shunt-dependent hydrocephalus and cerebral vasospasm. We reviewed a single-surgeon series to compare postsurgical outcomes of patients who underwent fenestration of the lamina terminalis against those who did not.

C3a receptor modulation of granulocyte infiltration after murine focal cerebral ischemia is reperfusion dependent.

The complement anaphylatoxin C3a contributes to injury after cerebral ischemia in mice. This study assesses the effect of C3a receptor antagonist (C3aRA) on leukocyte infiltration into the ischemic zone. Transient or permanent middle cerebral artery occlusion (MCAO) was induced in wild-type C57Bl/6 mice.

O-desulfated heparin improves outcome after rat cerebral ischemia/reperfusion injury.

Objective: Inflammatory cascades play a significant role in progressive neurological injury after transient cerebral ischemia. It has been demonstrated that heparin, a potent anticoagulant, also possesses anti-inflammatory properties that diminish postreperfusion damage after stroke. However, the potential for heparin to induce hemorrhagic transformation of an infarct has deterred its use in cases of focal cerebral ischemia.

Pre-clinical evaluation of an sLe x-glycosylated complement inhibitory protein in a non-human primate model of reperfused stroke.

Background: Soluble complement receptor-1 (sCR1), a potent complement inhibitor, confers neuroprotection in a murine stroke model. Additional neuroprotective benefit is achieved by sLe x-glycosylation of sCR1. In an effort to translate sCR1-sLe x to clinical trials, we evaluated this agent in a primate stroke model.

Herophilus, Erasistratus, Aretaeus, and Galen: ancient roots of the Bell-Magendie Law.

Since the early 19th century, significant controversy has persisted over the competing claims of two men, Charles Bell and François Magendie, to a pivotal discovery: that the dorsal spinal roots subserve sensation, whereas the ventral spinal roots subserve motion. However, the foundations of neuroanatomy on which Bell and Magendie built their research was formed two millennia in advance. Exploration of the work of four ancient scholars--Herophilus, Erasistratus, Aretaeus, and Galen--reveals a remarkable early appreciation of the separate neural pathways (if not the correct physiology) responsible for sensory and motor control.

Post-carotid endarterectomy neurocognitive decline is associated with cerebral blood flow asymmetry on post-operative magnetic resonance perfusion brain scans.

Objective: Up to 25% of patients experience subtle declines in post-operative neurocognitive function following, otherwise uncomplicated, carotid endarterectomy (CEA). We sought to determine if post-CEA neurocognitive deficits are associated with cerebral blood flow (CBF) abnormalities on post-operative MR perfusion brain scans.

Methods: We enrolled 22 CEA patients to undergo a battery of neuropsychometric tests pre-operatively and on post-operative day 1 (POD 1).

Early plasma complement C3a levels correlate with functional outcome after aneurysmal subarachnoid hemorrhage.

Objective: Studies have documented an inflammatory response in the circulating plasma and cerebrospinal fluid of patients with aneurysmal subarachnoid hemorrhage (aSAH). In particular, early upregulation of several complement proteins, including C3a, C4a, and C5b-9, has been demonstrated after the initial hemorrhagic insult. The inflammatory actions of the complement cascade are largely mediated through the anaphylatoxins, C3a and C5a.

Selection of a rigid internal fixation construct for stabilization at the craniovertebral junction in pediatric patients.

Object: Atlantoaxial and occipitocervical instability in children have traditionally been treated with posterior bone and wire fusion and external halo orthoses. Recently, successful outcomes have been achieved using rigid internal fixation, particularly C1-2 transarticular screws. The authors describe flow diagrams created to help clinicians determine which method of internal fixation to use in complex anatomical circumstances when bilateral transarticular screw placement is not possible.

Potential mechanisms and clinical significance of global cerebral edema following aneurysmal subarachnoid hemorrhage.

In an attempt to elucidate the pathophysiology and clinical significance of global cerebral edema (GCE) following aneurysmal subarachnoid hemorrhage (SAH), the authors explored potential mechanisms and reviewed findings associated with this phenomenon. Admission computed tomography (CT) scans show GCE in up to 20% of patients experiencing aneurysmal SAH. This edema is likely to have been initiated by transient global ischemia, as indicated by an association between ictal loss of consciousness and the development of edema.

External ventricular drainage response in poor grade aneurysmal subarachnoid hemorrhage: effect on preoperative grading and prognosis.

Introduction: The importance of preoperative response to external ventricular drainage (EVD) for treatment of acute hydrocephalus (HCP) following poor grade (Hunt & Hess grade IV or V) aneurysmal subarachnoid hemorrhage (aSAH) has not been clearly defined. The effect of EVD response on preoperative grade and prognosis is described.

Methods: Fifty-nine poor grade patients had an EVD placed preoperatively and underwent definitive aneurysm treatment between September 1996 and March 2002.

Advances in vasospasm treatment and prevention.

Outcome after aSAH depends on several factors, including the severity of the initial event, perioperative medical management, surgical variables, and the incidence of complications. Cerebral vasospasm (CV) is ure to consistently respond to treatment, emphasizing the need for further research into the underlying mechanisms of SAH-induced cerebrovascular dysfunction. To this end, our paper reviews the relevant literature on the main therapies employed for CV after aSAH and discusses possible avenues for future investigations.

Surgical management of cervical myelopathy: indications and techniques for laminectomy and fusion.

Background: Cervical spondylotic myelopathy (CSM) is a commonly encountered surgical disease that may be approached through a variety of operative techniques. Operative goals in the treatment of CSM include effective neural element decompression and maintaining spinal stability to avoid delayed deformity progression and neurologic compromise. Determining the most appropriate operative approach requires careful consideration of the patient's clinical presentation and radiographic imaging.

Long-term domain-specific improvement following poor grade aneurysmal subarachnoid hemorrhage.

Background: While efforts have been made to document short-term outcomes following poor grade aneurysmal subarachnoid hemorrhage (aSAH), no data exist concerning the degree of delayed improvement in neurological function. Here we assess cognitive function, level of independence, and quality of life (QoL) over 12 months following poor grade aSAH.

Methods: Data on definitively treated poor grade patients (Hunt and Hess grade IV or V) surviving 12 months post-aSAH were obtained through a prospectively maintained SAH database.

Preclinical evaluation of the neuroprotective effect of soluble complement receptor type 1 in a nonhuman primate model of reperfused stroke.

Object: Postischemic cerebral inflammatory injury has been extensively investigated in an effort to develop effective neuroprotective agents. The complement cascade has emerged as an important contributor to postischemic neuronal injury. Soluble complement receptor Type 1 (sCR1), a potent inhibitor of complement activation, has been shown to reduce infarct volume and improve functional outcome after murine stroke.

Ventriculoperitoneal shunting of idiopathic normal pressure hydrocephalus increases midbrain size: a potential mechanism for gait improvement.

Objective: Idiopathic normal pressure hydrocephalus (INPH) is characterized by a classic clinical triad of symptoms, including dementia, urinary incontinence, and gait disturbance. Recent work has demonstrated that the maximal midbrain anteroposterior (AP) diameter is significantly smaller in patients with INPH than in healthy, age-matched controls. The current study was undertaken to determine the effect of ventriculoperitoneal shunt placement on midbrain dimensions in INPH patients.

A review of current and future medical therapies for cerebral vasospasm following aneurysmal subarachnoid hemorrhage.

In an effort to help clarify the current state of medical therapy for cerebral vasospasm, the authors reviewed the relevant literature on the established medical therapies used for cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH), and they discuss burgeoning areas of investigation. Despite advances in the treatment of aneurysmal SAH, cerebral vasospasm remains a common complication and has been correlated with a 1.5- to threefold increase in death during the first 2 weeks after hemorrhage.