Malignant astrocytoma of the conus medullaris treated by spinal cordectomy.

We present a case of malignant astrocytoma of the conus medullaris in a 48-year-old man treated by spinal cordectomy. Preoperative examination revealed a tumor at the T12 to L1 level, and intraparenchymal invasion up to T8. The spinal cord was amputated caudally to the root entry zones of the T9 sensory roots. Additional cordectomies were repeated three times because of tumor infiltration at the cut end. At each procedure, the cord was segmentally transected just caudal to the root entry zones of the p reserving-aid sensory roots to minimize the neural deficit. The final transected level was between T3 and T4, and the cut end did not pathologically reveal any tumor invasion. However, the patient died from tumor recurrence and dissemination. Although the attempt to control the tumor by long segment cordectomy was unsuccessful, spinal cordectomy with wide margin may be a possible treatment for patients with malignant astrocytoma of the conus medullaris presenting with complete deficit below the lesion a nd no dissemination, if in an early stage.     

Intraoperative neurophysiologic monitoring and neurologic outcomes in patients with epidural spine tumors

Purpose

Multimodal intraoperative neurophysiologic monitoring (IOM) provides assessment of spinal cord pathways during neurosurgery. Despite widespread use, few data exist regarding sensitivity and specificity of IOM in predicting neurologic outcome during decompression and instrumentation for epidural spine tumors.

Methods

Retrospective analysis evaluated consecutive spine procedures involving IOM modalities (somatosensory evoked potentials [SSEP], motor evoked potentials [MEP], and electromyography [(EMG]) from 2007 to 2009. Demographic and surgical information, intraoperative neurophysiologic data, and pre- and postoperative neurologic status were collected. All cases involved neoplastic epidural spinal cord compression by a primary or metastatic tumor and included posterolateral decompression and instrumented fusion.

Results

Two-hundred and eight consecutive patients had spine surgery during this time period and one hundred and fifty-two met inclusion criteria. All patients had SSEP monitoring, with 4 having transient changes and 7 persistent changes. One hundred and twenty-two patients had combined SSEP and MEP monitoring, with 3 having transient changes and 4 persistent changes in MEP signals. Two patients had neurophysiologic changes associated with hypotension and correction led to normalization. One developed new neurologic deficits after surgery. Two from the total cohort had new postoperative neurologic deficits. One had a transient decrease in MEP amplitude while the other had no intraoperative changes.

Discussion

These cases are often long with significant blood loss, and stability of multiple IOM modalities provides reassurance that spinal cord function remains intact. Signal changes should result in scrutiny of blood pressure, surgical technique and anesthesia. Preserved IOM signals are suggestive of preserved neurologic outcome.     

Microsurgical clipping of previously coiled intracranial aneurysms

Objective

Endovascular coiling techniques for the treatment of intracranial aneurysms have rapidly developed as an alternative option to surgical clipping. A distinct problem after endovascular coiling is the management of a residual aneurysm neck due to incomplete filling, compaction of coils or regrowth of the aneurysm. Treatment options in this situation include surgical clipping, re-coiling, stent implantation or observation.

Methods

From June 2006 to August 2011, 15 patients underwent surgical clipping of residual or recurrent aneurysms after previous endovascular treatment. The mean age of the patients was 50.6 years (range, 27–85 years). The mean interval between coiling and clipping was 76.5 weeks (range, 0–288 weeks).

Results

Thirteen patients revealed a regrowth of coiled aneurysms, and in 5 patients compaction of coils was present. Coil extrusion was observed in 9 patients intraoperatively. In case of coil obstruction at the aneurysmal neck during surgery, coils were partially or completely removed. In all cases complete occlusion of the aneurysms was surgically achieved.

Conclusion

Coiled aneuryms with incomplete occlusion, coil compaction or regrowth of the aneurysmal neck can be successfully treated with microsurgical clipping. Coil extrusion was more often observed intraoperatively than expected. Complete occlusion of the aneurysm can be performed safely, even if loops of coils protrude into the aneurysmal neck. In these cases intraoperative removal of the coils enables secure closure of the aneurysm with a surgical clip.     

Surgical management of carcinoid tumors metastatic to the spine: Report of three cases

Background

Carcinoid tumors are rare, slow-growing neuroendocrine tumors that most frequently arise from the gastrointestinal tract or the lungs. Common sites of carcinoid metastases include lymph nodes, liver, lungs, and bone, with rare metastasis to the spine. We report three patients who presented with spinal cord compression secondary to carcinoid metastases to the spine.

Methods

Three patients presented with symptoms characteristic of spinal cord compression, including neck pain, radiculopathy, thoracic pain, weakness and numbness. All three patients underwent radiographic work-up and surgical treatment.

Results

One patient continued to have decreased strength in her right upper extremity, but was able to participate in physical therapy; another patient's numbness eventually resolved after completion of physical therapy; and the third patient's pain dramatically improved after surgery. One patient died more than two years post-surgery due to widespread metastasis; the other two remain alive more than two years post-surgery.

Conclusions

Carcinoid tumor metastases rarely cause spinal cord compression, but should be considered when patients present with neurological symptoms consistent with cord compression. Work-up should include magnetic resonance imaging (MRI), computed tomography (CT) of the spine, and perhaps CT-guided biopsy. Surgery is indicated for symptomatic spinal cord compression in patients with carcinoid tumors.     

Preoperative spinal tumor embolization: An institutional experience with Onyx

Background

Preoperative embolization has the potential to decrease intraoperative blood loss and facilitate spinal cord decompression and tumor resection.

Objective

We report our institutional experience with the embolization of hypervascular extradural spinal tumors with Onyx as well as earlier embolic agents in a series of 28 patients.

Methods

A retrospective case review was conducted on patients undergoing preoperative transarterial embolization of a spinal tumor between 1995 and 2012 at our institution.

Results

Twenty-eight patients met the inclusion criteria, with a mean age of 60.6 years. Twenty-eight patients had metastatic tumors. In 14 (50%) patients the metastases were from renal cell carcinomas. Fifty-four vessels were embolized using PVA, NBCA, Onyx, coils, or embospheres. Sixteen patients were treated with Onyx, 6 patients with PVA, 3 patients with embospheres, 2 patients with NBCA, and 3 patients with a combination of embolic agents. The average decrease in tumor blush was 97.8% with Onyx versus 92.7% with the rest of the embolic agents (p = 0.08). The estimated blood loss was 1616 ml (range 350–5000 ml). Blood loss was 750 cm³ on average with Onyx versus 1844 with the rest of the embolic agents (p = 0.14). The mean length of stay was 16 days. The mortality rate was zero. Pre- and post-operative modified Rankin Score (mRS) did not differ significantly in the series (3.12 versus 3.10, respectively, p = 0.9).

Conclusion

In our experience, the use of transarterial tumor embolization as an adjunct for spinal surgery is a safe and feasible option.     

Thoracic sensory level as a false localizing sign in cervical spinal cord and brain lesions

Background

In rare cases of cervical myelopathy, there may be a discrepancy between the sensory level and the site of cord lesion. This phenomenon is not well recognized. This study sought to investigate the characteristics of patients presenting with a false localizing thoracic sensory level.

Methods

The databases of the neurology clinics of two major tertiary medical centers were reviewed for all patients who presented in 2000–2010 with a main complaint of paraparesis and a thoracic sensory level. Those whose initial thoracic magnetic resonance scan showed no spinal cord pathology were included in the study.

Results

Twelve patients (mean age, 52 ± 31 years) met the study criteria. In all cases, the pathological lesion was visualized on magnetic resonance imaging of the cervical spine or brain. Eight patients had a compressive lesion of the spinal cord and 4 had demyelinating lesions. The difference between the false localizing sensory level and the level of the cervical lesion ranged from 6 to 11 segments.

Conclusion

Patients with a sensory thoracic level and normal findings on thoracic magnetic resonance imaging should be further evaluated with cervical spinal cord and, sometimes, brain imaging to search for potentially treatable lesions.     

Low field intraoperative MRI-guided surgery of gliomas: A single center experience

Introduction

The aim of this article is to report on our experience in using a low field intraoperative MRI (iMRI) system in glioma surgery and to summarize the hitherto use and benefits of iMRI in glioma surgery.

Patients and methods

Between July 2004 and May 2009, a total of 103 patients harboring gliomas underwent tumor resection with the use of a mobile low field iMRI in our institution. Surgeries were performed as standard micro-neurosurgical procedures using regular instrumentarium. All patients underwent early postoperative high field MRI to determine the extent of resection. Adjuvant treatment was conducted according to histopathological grading and standard of care.

Results

All tumors could be reliably visualized on intraoperative imaging. Intraoperative imaging revealed residual tumor tissue in 51 patients (49.5%), leading to further tumor resection in 31 patients (30.1%). Extended resection did not translate into a higher rate of neurological deficits. When analyzing survival of patients with glioblastoma, patients undergoing complete tumor resection did significantly better than patients with residual tumor (50% survival rate at 57.8 weeks vs. 33.8 weeks, log rank test p = 0.003), while younger age did not influence survival (p = 0.12).

Conclusion

Low field iMRI is a helpful tool in modern neurosurgery and facilitates brain tumor resection to a maximum safe extent. Its use translates into a better prognosis for these patients with devastating tumors. Future studies covering the use of iMRI will need to be conducted in a prospective, randomized fashion to prove the true benefit of iMRI in glioma surgery.     

Finding the anaplastic focus in diffuse gliomas: the value of Gd-DTPA enhanced MRI, FET-PET, and intraoperative, ALA-derived tissue fluorescence

Objective

Diffuse gliomas may harbor anaplastic foci which affect prognosis and determine adjuvant therapies. Such foci are not always detected by contrast-enhancement on MRI. Recently, other modalities have been introduced, such as FET-PET for pre-diagnostic imaging and 5-aminolevulinic derived tumor fluorescence for intraoperative identification of malignant glioma tissue. The relationship between these modalities and their value for guiding biopsies during resection has not yet been elucidated in the group of diffuse gliomas.

Methods

FET-PET was performed in 30 consecutive patients with intracerebral lesions suggestive of diffuse gliomas on MRI with or without areas of contrast-enhancement. Prior to surgery patients were given 5-ALA at a dose of 20 mg/kg body weight. Areas of FET uptake with a lesion/brain ratio of 1.6 or more were considered indicators of tumor. FET-PET data were corregistered with MRI data before surgery in order to obtain neuronavigated biopsies during resection, which were collected from FET positive and negative areas, analyzed for tumor fluorescence and correlated to contrast-enhancement on MRI.

Results

13 of 30 tumors were diagnosed as gliomas WHO Grade II, 15 as gliomas WHO Grade III and 2 as gliomas WHO Grade IV. The mean lesion/brain tissue ratio of FET uptake was significantly greater for high-grade than for low-grade gliomas (averages SD 2.323 ± 0.754 vs. 1.453 ± 0.538 p = 0.0014). A match of FET-pos/ALA-pos biopsies was found in 70.6% (12/17) of high-grade gliomas (WHO Grade III/IV) but only in 7.7% (1/13) of low grade gliomas. Gd-neg/FET-neg/ALA-neg biopsies yielded a low-grade tumor in 46.2% (6/13). A mismatch between FET uptake and 5-ALA (FET-pos/ALA-neg) was found in 46.2% (6/13) of the low-grade and in 17.6% (3/17) of the high-grade tumors. The combination of FET-PET- and 5-ALA-positivity yielded a sensitivity for identifying high-grade glioma foci of 70.5% and a specificity of 92.3%.

Conclusions

In low grade gliomas 5-ALA fluorescence is the exception and FET PET is more sensitive. High grade areas in diffuse gliomas with anaplastic foci usually fluoresce, if they are FET PET positive. As a result, FET PET appears valuable for pre-operative identification of anaplastic foci and hot spots are strongly predictive for ALA-derived fluorescence, which highlight anaplastic foci during resection.     

A systematic review of clinical outcomes, perioperative data and selective adverse events related to mild hypothermia in intracranial aneurysm surgery

Background

In the last two decades, mild intraoperative hypothermia has become widely accepted as a protective therapy in neurosurgery. However, its effect in intracranial aneurysm surgery remains unclear.

Objective

The purpose of this study was to assess the perioperative effects and selected adverse events associated with intraoperative mild hypothermia in aneurysm surgery and to compare those with events in normothermic surgery.

Methods

Three literature databases, namely the Cochrane Library, PubMed and EMBASE, were searched for randomised controlled trials (RCTs) of aneurysm surgery that compared intraoperative mild hypothermia and normothermia from January 1965 to August 2010. Three RCTs were identified. We extracted the following information: author names and publication year; clinical outcome (number of deaths and Glasgow outcome scales); perioperative data (number of moderate or severe intraoperative brain swelling occurrences, hypertensive episodes, ruptured or leaking aneurysms, volume of blood loss during surgery, duration of temporary clipping, and number of patients who received protective drugs, who required rewarming and who were intubated); number of adverse events (cerebral infarctions, brain swelling, myocardial ischaemia or infarction, congestive heart failure, meningitis or ventriculitis and pneumonia). Except for author names and publication year, the data were pooled to perform a mean effect size estimate. The effects of intraoperative mild hypothermia were then analysed.

Results

The number of patients requiring rewarming in the mild hypothermia group was significantly greater than in the normothermia group (odds ratio, 33.89; 95% confidence intervals, 3.61–318.36). There were no other statistically significant differences.

Conclusion

Based on available RCTs, especially involving surgery of low-grade aneurysms, intraoperative mild hypothermia showed no advantages compared with normothermia.     

Enhanced serum creatine kinase after neurosurgery in lateral position and intraoperative neurophysiological monitoring

Objective

Several cases of highly elevated serum levels of creatine kinase (CK) after surgical interventions have been described in the literature. A consensus on possible risk factors is still lacking. We therefore studied CK-levels in a large population of patients undergoing neurosurgical interventions and sought to determine possible risk factors.

Methods

We retrospectively analyzed 150 elective neurosurgical interventions where pre- and postoperative CK serum levels were determined. The cases were selected such that 50 patients were operated in lateral position and 100 in prone or supine position. During the hospital stay, routine clinical diagnostics were conducted, including medical status and laboratory examinations.

Results

In the patient group (median age 50, 63 male) there were 129 cranial and 21 spinal interventions. In 55 cases, intraoperative neurophysiological monitoring (IONM) was performed so that in these patients muscles were not relaxed pharmacologically. In a linear regression model, the maximal postoperative CK-level increased compared to baseline (p < 0.001). While age and obesity were not identified as risk factors, the CK-level was enhanced after surgery in lateral position (p < 0.001) and if IONM was performed (p = 0.04).

Conclusions

The strong association of postoperative serum CK-level with intraoperative positioning and IONM may be related to the elevated body pressure on the operating table in the lateral position, in particular if muscles are not relaxed pharmacologically, which was the case if intraoperative monitoring was performed. In these cases special care has to be taken for the positioning and during the peri-operative management.     

Clinical outcome of posterior fixation of the C1 lateral mass and C2 pedicle by polyaxial screw and rod

Objective

Because of atlantoaxial complex has a unique and complicated anatomy and instability of this complex is very dangerous. We investigated the clinical results of posterior C1–C2 fixation with a polyaxial screw–rod system.

Methods

Between July 2001 and December 2007, the authors treated 17 patients suffering from atlantoaxial deformity and instability. Atlantoaxial fusion was employed in 9 patients with upper cervical fracture and dislocation, in 6 patients with atlantoaxial subluxation, in 1 patient with pure transverse ligament injury, and in 1 patient with basilar invagination. The mean age at the time of surgery was 40.4 years (range, 15–68 years).

Results

Operative times ranged from 165 to 420 min (average 306 min), and the postoperative mean VAS score was 2.4. The mean follow-up period was 26 months. Solid fusion was achieved in 15 patients at the last follow up; no injury of the vertebral artery or spinal cord and no operative mortality occurred in these cases.

Conclusions

We suggest that posterior atlantoaxial fixation using the polyaxial screw–rod system is an effective and relatively safe technique. The navigation guidance system employed during the surgical procedure was helpful methods. Future studies of the feasibility of navigation system-guided surgical procedures will be required.     

Intramedullary cavernous malformations: Clinical features and surgical technique via hemilaminectomy

Objective

The purpose of this study was to define the clinical features and the surgical technique of unilateral hemilaminectomy for treating intramedullary cavernous malformations.

Materials and methods

Retrospective chart was performed in 16 patients with histologically diagnosed intramedullary cavernous malformations. All patients were treated with unilateral hemilaminectomy and microsurgical resection of the malformations. The pre- and postoperative neurological state was evaluated using Frankel scale.

Results

There were nine females and seven males (mean age 38 years) harbouring symptomatic intramedullary cavernous malformations. The annual retrospective haemorrhage rate was 3.1% per patient/year. All cavernous malformations were completely resected. Twelve of 16 patients experienced the improvement of the neurological state and in four patients, clinical features remained unchanged during the follow-up period. Static and dynamic plain radiograph film showed none of them had spinal deformity or spinal instability.

Conclusion

According to the defined bleeding risk, symptomatic and MRI-morphologically growing intramedullary cavernous malformations should be totally surgically removed, to avoid the recurrence and rebleeding of the residue. A least traumatic myelotomy, as well as a meticulous microsurgical technique and the intraoperative somatosensory evoked potentials monitoring, together with selection of a minimally invasive microsurgical approach (hemilaminectomy), leads to a favourable outcome and prevents additional morbidity.     

Management and outcome of primary spinal ependymomas: A single center experience from Taiwan

Background

Surgical treatment of spinal ependymomas requires careful consideration of the relative risks of neurological worsening from surgery. Our aim was to determine the risk factors of neurological deterioration after surgery for spinal ependymomas.

Material and methods

This 20-year study included 17 patients (seven men and 10 women; 44.65 ± 13.62 years) with histologically confirmed spinal ependymomas. The basic features were reviewed and the functional status was assessed by using the modified McCormick classification. We subdivided the patient population into two groups according to whether neurological deterioration occurred after primary tumor resection (N = 5) or not (N = 12), and compared their clinical characteristics.

Results

The average duration of presenting symptoms in the 17 patients was 23.53 ± 21.45 months. Three (17.6%) patients underwent subtotal or partial resection and 14 (82.4%) patients underwent gross total resection. The incidence of neurological deterioration after primary resection of spinal ependymomas was 29.4%. There were five (100%) and two (16.7%) male patients in the neurological-deterioration and no-deterioration groups, respectively (p = 0.003). The duration of presenting symptoms was 24 months or over in all the patients with neurological deterioration and five of the 12 patients with improved or stabilized function (p = 0.044).

Conclusion

The risk associated with surgical resection of spinal ependymomas should not be overlooked because of the significant incidence of neurological deterioration. The male gender and long-standing symptom (≥24 months) are risk factors of postoperative neurological worsening. Early diagnosis and surgery are therefore critical for successful treatment of spinal ependymomas.     

Morbidity following sural nerve harvesting: A prospective study

Objective

To evaluate donor site morbidity following sural nerve harvesting, with special attention to the recovery of sensory loss.

Methods

We prospectively followed 38 subjects who underwent sural nerve harvest, including two with bilateral nerve excision. Symptoms related to sural nerve excision were evaluated and demarcation of the area with reduced touch sensation was quantified. Assessments were performed periodically up to 1 year after surgery and the results of different sensory evaluations were compared.

Results

A significant reduction of sensory deficit was identified between consecutive evaluations (p < 0.05). Decreases of 26.85%, 20.69% and 24.29% were observed 3, 6 and 12 months after surgery, respectively. Shock-like pain (7.5%), stabbing pain (7.5%), and numbness (5%) were the most frequently reported symptoms. All symptoms were brief and resolved spontaneously 3–6 months after surgery.

Conclusion

Sural nerve harvest can be performed with acceptable morbidity. When present, symptoms resolve between the third and sixth month after surgery and a significant reduction of sensory loss in the area innervated by the sural nerve was observed during the first year of follow-up.     

Complications of anterior surgery in cervical spine trauma: an overview

Objective

Although anterior surgery for cervical spine injuries is a widespread procedure, articles regarding its overall complications are infrequently published in the literature. In the current study we focus on the complications encountered after anterior instrumented stabilization of cervical spine injuries and we discuss ways to minimize them.

Patients and methods

Patients with unstable lower cervical spine injuries who underwent anterior surgery over a 15-year period were identified and 74 patients with adequate follow-up were included in the study. Indication for surgery was set by the instability criteria of White and Panjabi. Demographic information, initial neurological examination, surgical reports, imaging findings and follow-up records were evaluated.

Results

Complications were classified as intraoperative (technique-related) and postoperative. Although radiological “complications” were noted, they had no or minor clinical consequences for the patient. We identified 9 patients with clinically significant complications: no purchase of the screws, late angulation deformity, screw breakage, backout of the screws and postoperative hematoma. Overall, 3 out of 74 patients (4%) were reoperated due to significant screw backout causing dysphagia, no purchase of the screws being completely in the adjacent disc and screw breakage, respectively.

Conclusion

Anterior surgery for cervical spine injuries can present several complications, yet the technique is in a way permissive, even during the learning curve. Considering the significant morbidity of these patients, the reported rate of clinically significant complications is considered acceptable, and it could be further minimized by good preoperative planning, careful surgical technique and the use of modern implants and instrumentation.     

¿Rombencefalomielitis aguda recurrente del adulto o neuromielitis óptica? A propósito de un caso

Introduction

The lack of accepted homogeneous criteria for the definition of some demyelinating diseases makes diagnostic characterization difficult and limits data interpretation and therapeutic recommendations. Recurrent encephalomyelitis (ADE-R) along with borderline cases of neuromyelitis optica (NMO) are especially controversial.

Objective

To describe the clinical and radiological evolution of an adult-onset ADE-R versus NMO case throughout 9 years of follow-up.

Patient and methods

Our patient presented with severe symptoms of rhombencephalomyelitis and the cranial and spinal magnetic resonance imaging (MRI) showed large lesions, with gadolinium enhancement in brainstem and spinal cord, correlating with the clinical picture. Infectious aetiology was excluded, IgG index was normal and NMO antibodies were negative. After treatment with intravenous corticosteroids and plasmapheresis, there was excellent recovery in the acute phase. During follow-up, seven relapses have occurred, mainly in the spinal cord, with good recovery and the same symptomatology, albeit with different severity. Immunosuppressive treatment was introduced since the beginning.

Conclusions

Our case shares common features of both ADE-R and NMO, illustrating that diagnostic characterization is not easy in spite of current criteria.     

Superparamagnetic beads for estimation of spinal subarachnoid space permeability in rats

Background

Human spinal pathological processes have been linked to a loss of spinal subarachnoid space (SSAS) permeability, which has therefore become a target for therapy. Hence, it has become important to measure SSAS patency in rat models of these human disorders.

New method

The estimation of in vivo rat SSAS patency is described by quantifying passage of streptavidin-covered superparamagnetic beads (SPMB) in cerebrospinal fluid (CSF). Beads are injected into the cisterna magna and recovered at spinal level L2. They are then coated with biotynilated horseradish peroxidase for enzymatically based colorimetric measurement, after removal of bloody CSF to avoid interference with the colorimetric readings. The procedure was tested in intact rats and in rats 24 h after T9 laminectomy. Residual beads in SSAS were viewed by histology.

Results

Average bead recovery from intact rats was 6.4% of amount initially administered, in a mean CSF volume of 126 μL; in laminectomized rats, it was 1%, in a mean CSF volume of 39.2 μL.

Comparison with existing method(s)

Unlike in vivo imaging techniques, such as myelography (used here to validate our method) and near infrared fluorescence technology for qualitative rat SSAS patency viewing, our SPMB-based method allows for an in vivo quantitative estimation of the permeability of this space.

Conclusions

A novel method has been established to reliably determine SSAS permeability in rats. The method is reproducible and has the required sensitivity to detect an 84.4% reduction in bead recovery, as seen in laminectomized rats compared to intact animals.     

The use of 5-aminolevulinic acid fluorescence guidance in resection of pediatric brain tumors

Introduction

Whereas in the adult population 5-Aminolevulinic acid (5-ALA) fluorescence guidance has been widely accepted for improving the extent of tumor resection, the application in children remains an off-label use. Even though most pediatric study protocols require a complete resection for improving outcome parameters, only few pediatric patients have been operated with fluorescence guidance, and it remains questionable, whether and which pediatric tumors show useful fluorescence. We present casuistic reports of application of 5-ALA in children collected from three different neurosurgical departments.

Patients and methods

In children with suspected malignant intracerebral tumor or recurrence, individual informed consent was obtained in each case from the parents. 5-ALA was administered according to the adult protocol, with 20 mg/kg, 2 h before induction of anesthesia. We retrospectively analyzed 18 patients (13 male, 5 female; age 3–18 years), using the intraoperative neurosurgical protocol, the postoperative MRI results, and the follow-up clinical examinations.

Results

The use of 5-ALA fluorescence guidance proved to be safe in our group of pediatric patients. Fluorescence guidance was most useful for recurrent glioblastoma resection. Medulloblastoma tissue displayed fluorescence only inconsistently, and most pilocytic astrocytoma remained without staining. Ganglioglioma showed partial staining in the central tumor areas, without allowing the use for circumferent resection.

Conclusion

The off-label use of 5-ALA fluorescence guidance in pediatric patients appears to be most useful in recurrent high-grade gliomas. Fluorescence accumulation in other pediatric brain tumor entities is not predictable and should be evaluated in future clinical studies before being integrated into the current treatment protocols.     

Preexisting cognitive status is associated with reduced behavioral functional capacity in patients 3 months after cardiac surgery: an extension study

Objective

To examine whether preexisting cognitive status rather than short- and middle-term postoperative cognitive decline (POCD) may differentially account for behavioral functional capacity 3 months after cardiac surgery.

Method

Seventy-nine patients completed a psychological evaluation, including the Trail Making Test Part B, the memory with 10-s interference, the phonemic fluency and the Instrumental Activities of Daily Living (IADLs) questionnaire for cognitive functions and behavioral functional capacity, respectively, before surgery, at discharge and at 3-month follow-up.

Results

Thirty-one (39%) and 22 (28%) patients showed POCD at discharge and at 3-month follow-up, respectively. Preoperative cognitive status was significantly associated with change in behavioral functional capacity 3 months after surgery (Ps<.003), whereas short- and middle-term POCD and intraoperative risk factors were unrelated to residualized change in IADLs scores (all Ps>.095).

Conclusions

Preexisting cognitive deficit, especially working memory deficit, rather than short- and middle-term POCD related to intraoperative risk factors is associated with poor behavioral functional capacity 3 months after cardiac surgery. The present study therefore suggests that a preoperative cognitive evaluation is essential to anticipate which patients are likely to show a decline in behavioral functional capacity after cardiac surgery.     

Spinal cord syrinx expansion following acquired Chiari malformation decompression: Case report

Objective

Chiari malformation development after lumboperitoneal (LP) shunting for pseudotumor cerebri is a recognized phenomenon. Treatment options for an acquired Chiari malformation include observation, LP shunt revision or ligation, ventriculoperitoneal (VP) shunt placement, and suboccipital decompression. The authors describe a case of suboccipital decompression of an acquired Chiari malformation that resulted in the development of a spinal cord syrinx.

Clinical presentation

A 24-year-old woman presented with headaches, photophobia, and blurred vision. No ventricular enlargement was seen on a computed tomographic scan of the brain. The patient was diagnosed with pseudotumor cerebri based on the clinical presentation and a lumbar puncture with a high opening pressure. She underwent an LP shunt. At the time of her 10-month follow-up evaluation, she was noted to have a symptomatic acquired Chiari malformation without a spinal cord syrinx.

Intervention

The patient underwent a suboccipital decompression to treat her Chiari malformation. Postoperatively, she developed an enlarging, symptomatic spinal cord syrinx. The patient underwent LP shunt ligation and VP shunt placement and had subsequent resolution of her spinal cord syrinx.

Conclusion

An enlarging spinal cord syrinx can occur following the suboccipital decompression of an acquired Chiari malformation in pseudotumor cerebri patients. Careful consideration to VP shunting should be given prior to posterior fossa decompression in such cases in an attempt to avoid syrinx development.