Microsurgical results with large vestibular schwannomas with preservation of facial and cochlear nerve function as the primary aim

Summary Objective. To evaluate our microsurgical results in dealing with vestibular schwannomas (VS) greater than or equal to 30 mm when preservation of cranial nerve function was considered more important than total tumour removal.Methods. Sixteen consecutive cases were operated on by the same neurosurgeon according to a prospective protocol using intraoperative neuro-monitoring (IONM) based on electromyographic and brain stem auditory evoked potential recordings. Facial nerve function was evaluated on the House-Brackmann Scale and cochlear nerve function on the Gardner-Robertson Scale. Someone not involved in the clinical management of our patients collected all data.Results. Fifteen patients showed facial nerve (FN) function of House-Brackmann grade (HBG) I or II at one year postoperatively and one kept the HBG IV she had preoperatively. Two patients of four maintained a cochlear nerve function of Gardner-Robertson grade (GRG) II. The tumour excision rates were: total, 68.7%; near total, 6.3%; subtotal, 18.7%, and partial, 6.3%. The average follow-up was 55 months (1–106). Three patients underwent radiotherapy later with growth stabilisation and no additional morbidity.Conclusion. When dealing with VS greater than or equal to 30 mm, microsurgery guided by IONM, with a rate of total or near-total tumour excision of about 75%, can retain socially acceptable facial nerve function (HBG I or II) in all cases and serviceable hearing (GRG I or II) in two cases out of four. Maintaining serviceable cranial nerve function should take precedence over total tumour excision.     

Remitting/relapsing idiopathic hypertrophic spinal pachymeningitidis: comprehensive imaging work-up and MR monitoring

We present the initial MR and PET work-up in a diabetic 31-year-old female patient presenting with spinal cord compression because of abnormal meningeal tissue and highlight the close correlation between the clinical course and the monitoring of the lesions on MR images. The combination of non-specific inflammatory signs at histopathological examination and of the negative results of a comprehensive bacteriological and serological testing led to the diagnosis of idiopathic hypertrophic spinal pachymeningitidis. The abnormal tissue showed mild glucose uptake at whole-body FDG-PET examination. Repeated MR follow-up examinations during corticoid treatment only demonstrated partial shrinkage of the abnormal tissue. Symptomatic relapse and re-increase in lesion size on MR images occurred concomitantly after an 11-month symptom-free remitting interval under tapering corticoid treatment.     

Local Anaesthesia for Fiberoptic Intubation : A Comparison of Three Techniques

Background

The successful conduct of fiberoptic aided intubation is dependent upon effective local anaesthesia. The aim of the study was to compare three different methods of anaesthetizing the airway.

Methods

60 adult patients (American Society of Anaesthesiologists status I-III and Mallampati class III & IV), scheduled for elective surgery, received sedation followed by spraying of the nares and posterior pharyngeal wall with 4% lignocaine. Thereafter the patients received 4 ml of 4% lignocaine either by transtracheal injection (n=20, group A), via intubating fiberscope (Pentax F1-10P2) using ‘spray as you go’ technique (n=20, group B) or by nebulizer (Devilbiss 5610W) 20 min before intubation, (n=20, group C). Patients were asked to score the procedure using visual analog scale (VAS) and severity scores. Episodes of coughing, choking, stridor, extra / total local anaesthetic used and intubation times were recorded. Patients were monitored continuously for vital parameters.

Results

Group B patients showed better VAS scores with shorter intubation times and had a lower incidence of coughing and choking. The endoscopists’ VAS scores also showed a preference for group B.

Conclusion

In conclusion the ‘spray as you go’ technique was safe, provided effective local anaesthesia and was preferred by both patients and endoscopists.Key Words: Awake intubation, Difficult airway, Fiberoptic intubation     

High signal intensity of intervertebral calcified disks on T1-weighted MR images resulting from fat content

Objective To explain a cause of high signal intensity on T1-weighted MR images in calcified intervertebral disks associated with spinal fusion.Design and patients Magnetic resonance and radiological examinations of 13 patients were reviewed, presenting one or several intervertebral disks showing a high signal intensity on T1-weighted MR images, associated both with the presence of calcifications in the disks and with peripheral fusion of the corresponding spinal segments. Fusion was due to ligament ossifications (n=8), ankylosing spondylitis (n=4), or posterior arthrodesis (n=1). Imaging files included X-rays and T1-weighted MR images in all cases, T2-weighted MR images in 12 cases, MR images with fat signal suppression in 7 cases, and a CT scan in 1 case. Histological study of a calcified disk from an anatomical specimen of an ankylosed lumbar spine resulting from ankylosing spondylitis was examined.Results The signal intensity of the disks was similar to that of the bone marrow or of perivertebral fat both on T1-weighted MR images and on all sequences, including those with fat signal suppression. In one of these disks, a strongly negative absorption coefficient was focally measured by CT scan, suggesting a fatty content. The histological examination of the ankylosed calcified disk revealed the presence of well-differentiated bone tissue and fatty marrow within the disk.Conclusion The high signal intensity of some calcified intervertebral disks on T1-weighted MR images can result from the presence of fatty marrow, probably related to a disk ossification process in ankylosed spines.     

Surgical treatment of a syringomyelia associated with an idiopathic arachnoid malformation disclosed by preoperative MRI

BACKGROUND: We describe the very rare condition of an idiopathic spinal arachnoid malformation associated with syringomyelia (SM) and depicted on preoperative magnetic resonance imaging (MRI) whose features were confirmed at surgery. CASE DESCRIPTION: A 34-year-old female suffered from progressive gait impairment because of lower limb palsy and sensory disturbances. MRI demonstrated a bulging membrane at the T6 level that was transversely stretched between the dorsal aspect of the spinal cord and the posterior dura mater. At this level, the spinal cord appeared atrophic and pushed anteriorly against the dura with enlargement of the posterior subarachnoid spaces (SAS) and focal collapse of an associated panmedullar SM. Surgery consisted in releasing the arachnoid malformation and opening the inferior segment of the syringomyelic cavity. Pathological examination revealed a fibro-sclerotic tissue with cellular areas of meningo-endothelial cells. Postoperative neurological status progressively improved but slightly. Three-months and 1 year postoperatively, MRI showed the collapse of the whole SM and restoration of cerebrospinal fluid (CSF) flow at the treated T6 level. CONCLUSION: Spinal arachnoid malformations associated with SM are very rare and have never been described up to now on MRI. Surgical removal of the causative malformation allows spinal cord decompression and prevents the recurrence of the SM by restoring normal CSF circulation.     

Pain relief following Arthroscopy - a comparative study of Intra-articular Bupivacaine,Morphine and Neostigmine

Pain after arthroscopy is quite distressing. Intra-articular bupivacaine produces transient analgesia and reports of analgesia using intra-articular opioids have produced conflicting results. Recently, spinal administration of neostigmine was shown to produce dose-dependant analgesia. However, this was limited by adverse effects. The purpose of this study was to compare the effects on intra-articular neostigmine, bupivacaine and morphine. 75 patients were randomized to receive intra-articular saline, bupivacaine, morphine, neostigmine and bupivacaine-neostigmine after arthroscopic surgery under spinal anaesthesia. Visual analog pain scores (VAS), duration of analgesia as defined as time for first demand for parenteral opioids and the total subsequent consumption of morphine was evaluated. Intra-articular bupivacaine resulted in significant VAS reduction at one and four hours as compared to those receiving intra-articular saline and morphine. Analgesia lasted longer after 500ugm intra-articular neostigmine as compared with bupivacaine, morphine or saline. The need for supplementary analgesia was lowest in the neostigmine group as compared to the other groups. No significant difference was found if bupivacaine was added to neostigmine. Among all the groups, no significant side-effects were observed.Key Words: Arthroscopy, Bupivacaine, Morphine, Neostigmine     

Uncommon magnetic resonance imaging observation of lumbar subdural hematoma with cranial origin

A patient with a history of pain, paresthesias, and weakness in both legs is reported. Magnetic resonance imaging (MRI) of the lumbar spine demonstrated subacute subdural hematoma. Brain MRI obtained 1 day later because of progressive headache showed hemorrhagic cortical metastasis and extensive subdural hematoma. It is hypothesized that the lumbar hematoma originated from the intracranial bleeding, which was substantiated by the observation of a thin hemorrhagic collection connecting cranial and lumbar hematomas on MRI. Cranial origin should be included in the differential diagnosis of spontaneous spinal subdural hematomas.     

Familial bilateral medial parietooccipital band heterotopia not related to DCX or LIS1 gene defects

A father and his daughter displayed strictly similar focal brain dysplasia at MR examination, characterized by regional medial posterior laminar sub-cortical grey matter heterotopia. To our knowledge, no family presenting such anomalies has yet been described. LIS1 and DCX gene defects were excluded. Collecting patients with such inherited dysplasia should improve our knowledge of the genetic basis of cortical malformations.     

Pancreaticoduodenectomy with vascular reconstruction for adenocarcinoma of the pancreas with borderline resectability

AIM: To analyze whether pancreaticoduodenectomy with simultaneous resection of tumor-involved vessels is a safe approach with acceptable patient survival.METHODS: Between January 2001 and March 2012, 136 patients received pancreaticoduodenectomy for adenocarcinoma at our hospital. Seventy-eight patients diagnosed with pancreatic head carcinoma were included in this study. Among them, 46 patients received standard pancreaticoduodenectomy (group 1) and 32 patients received pancreaticoduodenectomy with simultaneous resection of the portal vein or the superior mesenteric vein or artery (group 2) followed by reconstruction. The immediate surgical outcomes and survivals were compared between the groups. Fifty-five patients with unresectable adenocarcinoma of the pancreas without liver metastasis who received only bypass operations (group 3) were selected for additional survival comparison.RESULTS: The median ages of patients were 67 years (range: 37-82 years) in group 1, and 63 years (range: 35-86 years) in group 2. All group 2 patients had resection of the portal vein or the superior mesenteric vein and three patients had resection of the superior mesenteric artery. The pancreatic fistula formation rate was 21.7% (10/46) in group 1 and 15.6% (5/32) in group 2 (P = 0.662). Two hospital deaths (4.3%) occurred in group 1 and one hospital death (3.1%) occurred in group 2 (P = 0.641). The one-year, three-year and five-year overall survival rates in group 1 were 71.1%, 23.6% and 13.5%, respectively. The corresponding rates in group 2 were 70.6%, 33.3% and 22.2% (P = 0.815). The one-year survival rate in group 3 was 13.8%. Pancreaticoduodenectomy with simultaneous vascular resection was safe for pancreatic head adenocarcinoma.CONCLUSION: The short-term and survival outcomes with simultaneous resection were not compromised when compared with that of standard pancreaticoduodenectomy.