The efficacy and cost of prophylactic and perioprocedural antibiotics in patients with external ventricular drains.

OBJECTIVE: Prophylactic antibiotics are routinely administered to patients with external ventricular drains (EVDs); however, no conclusive evidence supports this practice. This study compared the efficacy and cost of prophylactic and periprocedural antibiotics in patients with EVDs. METHODS: We reviewed the charts of 308 patients who had an EVD in place for 3 or more days between January 1996 and June 1997. Patients with EVDs placed for shunt infections or meningitis were excluded. A standard protocol was used to insert and monitor EVDs. Catheters were left in place as long as clinically indicated and changed only if they malfunctioned. Cerebrospinal fluid cultures were obtained twice weekly. Prophylactic antibiotics were used at the discretion of the attending neurosurgeon. Patients were divided into two groups: Group A comprised 209 patients who received prophylactic antibiotics for the duration of the EVD (intravenously administered cefuroxime, 1.5 g every 8 h); Group B comprised 99 patients who received only periprocedural antibiotics (intravenously administered cefuroxime, 1.5 g every 8 h, three or less doses). RESULTS: Although there were significantly more males in Group A than in Group B, the two groups were otherwise well matched, with no significant differences in age, indications, or duration of EVD placement. The overall rate of ventriculitis was 3.9%. The infection rates for Group A (3.8%) and Group B (4.0%) were almost identical. CONCLUSION: Prophylactic antibiotics did not significantly reduce the rate of ventriculitis in patients with EVDs, and they may select for resistant organisms. Discontinuing the use of prophylactic antibiotics for EVDs at the authors' institution would save approximately $80,000 per year in direct drug costs.

Osteosarcoma of the temporal fossa with hemorrhagic presentation: case report.

OBJECTIVE AND IMPORTANCE: Excluding tumors of hematopoietic origin, osteosarcomas are the most common bone tumor, although involvement of the brain or cranial base is rare. CLINICAL PRESENTATION: A 16-year-old girl with an osteosarcoma of the temporal fossa presented with an intracerebral hemorrhage. The management strategy of this lesion, including the operative interventions, is described. INTERVENTION: Several modes of treatment were undertaken, including radical resection of the cranial base lesion and excision of the cavernous sinus after a cervical internal carotid artery-to-middle cerebral artery vein bypass graft. CONCLUSION: The patient was alive and without evidence of disease 11 months after presentation but died shortly thereafter of complications related to adjuvant therapies.

Intracranial extraskeletal mesenchymal chondrosarcoma: case report.

OBJECTIVE AND IMPORTANCE: We present a patient with a dural-based intracranial extraskeletal mesenchymal chondrosarcoma, which was initially thought to be an atypical meningioma. This rare tumor should be considered in the differential diagnosis of young adults with an aggressive-appearing dural-based lesion. CLINICAL PRESENTATION: A 21-year-old woman reported a 3-week history of severe headaches and intermittent nausea and vomiting. Neurological examination revealed right optic nerve swelling. Magnetic resonance imaging demonstrated a large, intensely enhancing extra-axial mass, which appeared to originate from the right side of the falx cerebri with significant mass effect. A presumptive diagnosis of meningioma was made. INTERVENTION: The patient underwent preoperative embolization of the lesion and then underwent a bicoronal craniotomy, gross total resection of the tumor, removal of invaded calvarial bone, and cranioplasty. Pathological examination revealed an extraskeletal mesenchymal chondrosarcoma. Because of the potential for recurrence, the patient received subsequent radiotherapy. She remains free of recurrence 18 months after surgery. CONCLUSION: Intracranial mesenchymal chondrosarcoma is a rare neoplasm that can mimic a meningioma radiographically. We present the first patient in whom this lesion has been documented with computed tomography, cardiography, magnetic resonance imaging, and pathological findings. We emphasize the importance of gross total resection and close follow-up for this potentially aggressive tumor, and we present a review of the literature.

The arteriovenous malformation associated with major arterial occlusion and moyamoya vessels: a cerebral blood flow study.

SUMMARY: We report 2 patients with arteriovenous malformation (AVM) associated with complete occlusion of the unilateral middle cerebral artery and moyamoya vessels. Xenon CT CBF study demonstrated diffusely decreased CMF in unilateral or bilateral hemispheres with multiple areas of decreased vascular reserve. A significant reduction of AVM size was seen in one patient who received radiosurgery with marked CBF improvement.

Transarterial Embolisation of Dural Arteriovenous Fistula Involving an Isolated Segment of the Superior Petrosal Sinus. A Case report.

SUMMARY: This case report illustrates a relatively rare case of dural arteriovenous fistula (AVF) involving direct supply to an isolated segment of the superior petrosal sinus (SPS). Successful transarterial obliteration of the lesion was accomplished with only a liquid embolic agent with long-term angiographic and clinical cure.

Long-term survival of a patient with invasive cranial base rhinocerebral mucormycosis treated with combined endovascular, surgical, and medical therapies: case report.

OBJECTIVE: Rhinocerebral mucormycosis is a clinical syndrome resulting from an opportunistic infection caused by a fungus of the order Mucorales. The prognosis of rhinocerebral mucormycosis, once considered uniformly fatal, remains poor. Even with early diagnosis and aggressive surgical and medical therapy, the mortality rate is high. We present a patient with rhinocerebral mucormycosis involving the paranasal sinuses and cranial base who experienced long-term survival after multimodality treatment. Clinical characteristics of the disease are discussed, and the literature is reviewed. CLINICAL PRESENTATION: A 24-year-old diabetic man presented with invasive rhinocerebral mucormycosis involving the paranasal sinuses, right middle fossa, and right cavernous sinus. INTERVENTION: The patient underwent endovascular sacrifice of the involved carotid artery and radical resection of the cranial base, including exenteration of the cavernous sinus. Reconstruction with a local muscle flap was performed. He continued to receive intravenous and intrathecal administration of antibiotics. CONCLUSION: Long-term survival with invasive rhinocerebral mucormycosis is rare, but possible, with aggressive multimodality treatment, including carotid sacrifice for en bloc resection of the pathology, when indicated.

Analysis of cyclin dependent kinase inhibitors in malignant astrocytomas.

The cyclin-dependent kinase inhibitors p16, p21, and p27 in human brain, and brain tumors were examined to explore clinicopathologic correlations. Western analysis and immunohistochemistry was performed and correlated retrospectively with the patients clinical characteristics. A trend was found between increased progression-free survival and p27 expression. There was no correlation between p27 expression and age or gender. The expression of p27 in malignant gliomas may have prognostic value. In addition, an investigation of the therapeutic benefit of overexpression of this cyclin-dependent kinase inhibitor is warranted given reports of diminished malignant potential of tumors expressing p27.

Surgical management of angiographically occult spinal dural arteriovenous fistulae (type I spinal arteriovenous malformations): three technical case reports.

OBJECTIVE AND IMPORTANCE: Spinal dural arteriovenous fistulae (Type I spinal arteriovenous malformations [AVMs]) have been recognized as a treatable cause of progressive myelopathy. The diagnosis and characterization of these lesions rest heavily on spinal angiography. CLINICAL PRESENTATION: We present three patients whose clinical presentations were consistent with a spinal dural AVM but whose spinal angiographic results were negative. INTERVENTION: The surgical treatment of these angiographically occult spinal AVMs is described. In retrospect, in each case, the feeding vessel to the AVM was injected but not seen. CONCLUSION: Some spinal dural arteriovenous fistulae will be angiographically occult. If the clinical and radiographic presentations strongly suggest the presence of an arteriovenous fistula, surgical exploration should be considered.

Microsurgical anatomy of the artery of Adamkiewicz and its segmental artery.

OBJECT: The blood supply of the lower spinal cord is heavily dependent on the artery of Adamkiewicz, which characteristically originates from one of the thoracolumbar segmental arteries. The aforementioned artery is of enormous clinical, surgical, and radiological importance, and the goal of this study was to elucidate the course and branches of the segmental artery that gives rise to this important vessel. METHODS: In this cadaveric, microsurgical anatomical study, the authors investigate and describe the course and branches of the artery of Adamkiewicz and the segmental branch from which it ultimately originates. A review of the literature is provided. CONCLUSIONS: By documenting the microsurgical anatomy of these important vessels, this study facilitates an understanding of the anatomy that will aid in treatment planning for surgery of various lesions in this area.

Microsurgical anatomy of the dorsal cervical nerve roots and the cervical dorsal root ganglion/ventral root complexes.

BACKGROUND: It is known that a "dissociated motor loss" of the deltoid muscle can occur with disconcerting frequency after cervical spine surgery. The etiology of this entity is in question. We conducted an anatomic study to identify anatomic factors that might predispose C5 to injury. METHODS: We studied 128 dorsal cervical nerves and root ganglion/ventral root complexes in 10 adult cadavers. At each cervical level the following data were recorded: number of rootlets, range of width of rootlets, length of DREZ, cranial angles of the superior and inferior rootlets with the spinal cord, length of the superior and inferior rootlets, dimensions of the foramina, dimensions of the dorsal root, dimensions of the dorsal root ganglion (DRG)/ventral root (VR) complex, and the blood supply to the DRG. The histology at the site of compression was also examined. Statistical analysis was conducted using the single factor-repeated measures analysis of variance. RESULTS: We found that, 1) the C5 superior dorsal rootlets angle less inferiorly from the cervical cord than the other dorsal cervical roots (p=0.001), 2) the majority of the DRG/VR complexes from C3 to C6 were compressed by the vertebral artery (73%), 3) the C5 DRG/VR complex was compressed to the greatest extent (77.6%, p=0.3519), and 4) the ganglionic artery was more frequent at C4, C5, and C6. CONCLUSION: To our knowledge, the second finding has not been reported previously. The first and third findings may help explain why C5 is more vulnerable to injury.

Lipomatous glioneurocytoma of the posterior fossa with divergent differentiation: case report.

OBJECTIVE AND IMPORTANCE: We report a case of a posterior fossa neuroepithelial tumor with unusual clinical presentation, magnetic resonance imaging appearance, and morphological features. CLINICAL PRESENTATION: This 66-year-old man presented with a history of gait ataxia, dizziness, and tinnitus and was found to have a large tumor in the posterior fossa and cerebellopontine angle. INTERVENTION: Gross total excision of the tumor was accomplished. Histologically, the most unique features were macrovesicular accumulations of lipid, giving the tumor (at least focally) an appearance virtually identical to that of mature adipose tissue. Evidence of biphasic neuronal and glial differentiation was noted by immunohistochemistry and electron microscopy. CONCLUSION: A literature review is presented. Diagnostically, this neoplasm seems to fit in a unique group of rarely described, lipomatous neuroectodermal tumors that show divergent neuronal and glial differentiation.

Bilateral persistent trigeminal arteries associated with cerebral aneurysms and aortic arch vessel anomaly.

We present the case of a patient with headache who, on computed tomography, was found to have subarachnoid hemorrhage. Angiography revealed bilateral persistent trigeminal arteries, anterior communicating artery and left pericallosal artery aneurysms, and an absent left vertebral artery. An anomalous right subclavian artery, originating at a common trunk with the left subclavian artery, was also present. To our knowledge, this is the fifth case of bilateral persistent trigeminal arteries and the sixth case of bilateral persistent carotid-basilar anastomosis of any type reported in the literature. A mechanism for the pathogenesis of multiple cerebrovascular anomalies is briefly discussed.

Stereotactic radiosurgery of malignant and benign intracranial lesions utilizing a patient rotator.

This study examines the characteristics of the patient groups, treatment parameters, and results of therapy for 126 intracranial lesions treated with stereotactic radiosurgery utilizing a "patient rotator" and a linear accelerator. A retrospective review was conducted and data on 122 patients (21 patients with arteriovenous malformations-AVMs, 40 patients with 41 metastatic tumors, 24 patients with malignant gliomas and 37 patients with other benign lesions) were analyzed. Clinical and radiographic response was obtained from chart review and/or telephone follow-up. The average follow-up was 12.1, 13.0, 5.7, and 23.1 months in patients with AVMs, malignant gliomas, metastases, and other lesions, respectively. Median survival times (MST) of the metastatic and glioma group were 9 and 38 months, respectively. Complete or partial radiographic response at follow-up was seen in 62.5% of AVM patients, 33.3% of patients with metastases, 11.8% of patients with malignant gliomas, and 19.3% of patients with other lesions. (1) Local control of brain metastases and benign intracranial lesions can be obtained with single dose stereotactic radiosurgery. (2) The MST and local control rate for metastatic disease obtained are comparable with those in the literature. (3) The patient rotator method for stereotactic radiosurgery is an effective tool for treating selected intracranial lesions.

Cranial migration of a lumboperitoneal shunt catheter.

We describe a patient with pseudotumor cerebri for which a lumboperitoneal (LP) shunt was placed. After a pseudomeningocele was noted at the lumbar incision site, an LP shunt revision was done, at which time migration of the catheter into the thecal sac was noted. Three months later, radiologic studies revealed cranial migration of the LP shunt into the posterior fossa. We believe no similar complication has been reported.

Intracranial adenoid cystic carcinoma: case report and review of the literature.

BACKGROUND: Adenoid cystic carcinoma (cylindroma) is a relatively common head and neck tumor that is slow growing, but locally aggressive and thus prone to recurrence. It is of particular interest to neurosurgeons and neurologists because of its tendency to locally infiltrate neural structures and to spread perineurally. Intracranial involvement has been regarded as rare. METHODS: A case report of a patient with adenoid cystic carcinoma involving the Gasserian ganglion region is presented. The world literature on intracranial involvement of adenoid cystic carcinoma is reviewed. A discussion of the characteristics of this lesion is provided. RESULTS: Our literature review revealed 119 previously reported cases of adenoid cystic carcinoma with intracranial involvement. Our case represents only the tenth reported intracranial case with an unknown primary site. CONCLUSIONS: Although intracranial adenoid cystic carcinoma is regarded as rare, we have accumulated over 100 such reports. A wide variety of primary sites and intracranial sites have been described.

Corpectomy and stabilization with methylmethacrylate in patients with metastatic disease of the spine: a technical note.

Corpectomy with methylmethacrylate reconstruction and stabilization in patients with metastatic disease of the spine has been performed for several years. Stainless steel Steinmann pins or K-wires are commonly used to facilitate fixation of the acrylic to the vertebral bodies above and below the resection site. The use of these ferromagnetic substances precludes the optimal use of magnetic resonance imaging in the postoperative period. We now report the use of commercially available titanium screws in conjunction with the methylmethacrylate to eliminate this problem and provide for improved postoperative imaging.

Immune response in hosts with cadaveric dural grafts. Report of two cases.

The use of cadaveric human dura has been critical in the repair of dural defects since the dawn of neurosurgery. Reports in the literature of immune response to this type of graft have been extremely rare. Two patients are presented who received cadaveric dural implants with resulting meningeal signs and cerebrospinal fluid eosinophilia several weeks after surgery. Peripheral eosinophilia was present in one patient. The signs and symptoms resolved temporarily during corticosteroid therapy and permanently upon removal of the offending grafts. These cases illustrate that an immune-type reaction can occur with significant morbidity in patients receiving cadaveric dural grafts. A proposed mechanism for this response is discussed.