Brain injury and neural stem cells.

Many therapies with potential for treatment of brain injury have been investigated. Few types of cells have spurred as much interest and excitement as stem cells over the past few decades. The multipotentiality and self-renewing characteristics of stem cells confer upon them the capability to regenerate lost tissue in ischemic or degenerative conditions as well as trauma. While stem cells have not yet proven to be clinically effective in many such conditions as was once hoped, they have demonstrated some effects that could be manipulated for clinical benefit. The various types of stem cells have similar characteristics, and largely differ in terms of origin; those that have differentiated to some extent may exhibit limited capability in differentiation potential. Stem cells can aid in decreasing lesion size and improving function following brain injury.

Hormonal therapy in traumatic spinal cord injury.

Traumatic spinal cord injuries are major health problems and the underlying pathophysiological events and treatment strategies are currently under investigation. In this article, we critically reviewed the literature investigating the effects of estrogen, progesterone, and human chorionic gonadotropin on spinal cord damage or preservation following traumatic spinal cord injury. The National Library of Medicine database was searched through December 2016 using PubMed for articles addressing the clinical relevance of the hormones to improve neural structural integrity following traumatic spinal cord injury. It was found that each of these hormones, through varied mechanisms, could serve to reduce the harmful effects associated with spinal cord injury, and could aid in restoring some function to the injured spinal cord in the animal models. The most striking effects were seen in the reduction of inflammation commonly linked to injury of the central nervous system. The effects of human chorionic gonadotropin administration following spinal cord injury have received far less attention than those of either estrogen or progesterone, and additional inquiry could be of general benefit. In this article, we discussed the outstanding questions and suggested future directions for further investigation.

Endoscopic Third Ventriculostomy in 250 Adults With Hydrocephalus: Patient Selection, Outcomes, and Complications.

BACKGROUND: Endoscopic third ventriculostomy (ETV) has been used predominantly in the pediatric population in the past. Application in the adult population has been less extensive, even in large neurosurgical centers. To our knowledge, this report is one of the largest adult ETV series reported and has the consistency of being performed at 1 center. OBJECTIVE: To determine the efficacy, safety, and outcome of ETV in a large adult hydrocephalus patient series at a single neurosurgical center. In addition, to analyze patient selection criteria and clinical subgroups (including those with ventriculoperitoneal shunt [VPS] malfunction or obstruction and neurointensive care unit patients with extended ventricular drainage before ETV) to optimize surgical results in the future. METHODS: We conducted a retrospective review of adult ETV procedures performed at our center between 2000 and 2014. RESULTS: The overall rate of success (no further cerebrospinal fluid diversion procedure performed plus clinical improvement) of 243 completed ETVs was 72.8%. Following is the number of procedures with the success rate in parentheses: aqueduct stenosis, 56 (91%); communicating hydrocephalus including normal pressure hydrocephalus, nonnormal pressure hydrocephalus, and remote head trauma, 57 (43.8%); communicating hydrocephalus in postoperative posterior fossa tumor without residual tumor, 14 (85.7%); communicating hydrocephalus in subarachnoid hemorrhage without intraventricular hemorrhage, 23 (69.6%); obstruction from tumor/cyst, 42 (85.7%); VPS obstruction (diagnosis unknown), 23 (65.2%); intraventricular hemorrhage, 20 (90%); and miscellaneous (obstructive), 8 (50%). There were 9 complications in 250 intended procedures (3.6%); 5 (2%) were serious. CONCLUSION: Use of ETV in adult hydrocephalus has broad application with a low complication rate and reasonably good efficacy in selected patients.

Thoracic venous congestion caused by thoracic disc herniation.

We present what is to our knowledge the first reported case of thoracic disc herniation leading to venous congestive myelopathy (VCM), which was clinically and radiographically suggestive of Foix-Alajouanine syndrome (angiodysgenetic necrotizing myelopathy). In addition, we review current concepts in evaluating the etiology of VCM and discuss indications for surgery.

Endoscopic third ventriculostomy for hydrocephalus after perimesencephalic subarachnoid hemorrhage: initial experience in three patients.

BACKGROUND: To review the outcome after endoscopic third ventriculostomy (ETV) for symptomatic, persistent hydrocephalus in three patients with perimesencephalic angiographically negative subarachnoid hemorrhage (PNH) who were dependent on an external ventricular drain (EVD). METHODS: All patients initially presented with severe headache, nuchal rigidity, confusion and lethargy (Hunt-Hess Grade II or III), and persistent, EVD-dependent hydrocephalus. Cranial CT images in each revealed acute hydrocephalus and perimesencephalic hemorrhage pattern with a heavy clot burden (Fisher grade 3). A 3D-CT angiogram on admission and two four-vessel cerebral angiograms failed to demonstrate a bleeding source. All three patients failed trial EVD clamping, with clinical deterioration and elevated intracranial pressure (ICP). ETV was performed with a 0-degree endoscope in a 4.6-mm irrigating sheath using an endoscopic-coring/"cookie-cut" technique. An EVD was left in place for postoperative ICP monitoring but was clamped. RESULTS: ETV was accomplished in all patients. In one case, a tiny basilar tip aneurysm was seen during the endoscopic procedure. Intraoperatively, the prepontine cistern revealed dense, degraded blood products. Postprocedure ICP measurements were reduced to normal range. Clinical improvement, normal ICP readings, and/or radiographic evidence of resolution of hydrocephalus allowed uneventful removal of the EVD within 36-48 h post-ETV in all patients. All remained headache-free, with a normal neurological examination, during a follow-up period of 10, 11, and 12 months, respectively. CONCLUSION: To our knowledge, this is the first report of ETV for PNH with hydrocephalus and the first report of a basilar tip microaneurysm seen intraoperatively during ETV. ETV is a viable treatment option for refractory hydrocephalus secondary to a perimesencephalic pattern of subarachnoid hemorrhage (SAH). Its early application can avoid placement of a ventriculoperitoneal shunt, curtail the extended use of an EVD, and reduce the associated infection risks. Despite thorough angiographic investigation for an aneurysmal cause of SAH, a "microaneurysm" of the basilar artery was found at ETV. No complication or rebleeding was encountered.

Elective stenting for intracranial stenosis under conscious sedation.

BACKGROUND: Elective stenting for intracranial stenosis is under study as an effective means of reducing stroke risk. At most institutions, these procedures are performed and monitored after the induction of general anesthesia. OBJECTIVE: To report our success with elective intracranial stenting and angioplasty performed in conscious patients after the administration of mild sedatives and local anesthetic agents. METHODS: We retrospectively evaluated data from 66 patients who underwent elective intracranial stenting for atherosclerosis. Sixty-one procedures were performed under local anesthesia with mild sedation; 3 were performed under general anesthesia, and 2 were converted from local to general anesthesia during the procedure. Intraprocedural neurological changes were monitored and led to reevaluation of technique, immediate reimaging, modifying the endovascular procedure itself, or possibly mandating conversion to general anesthesia. RESULTS: Thirty-nine anterior and 27 posterior circulation stenotic segments were treated. Angiographic success was achieved in 95.5% of patients with an overall reduction in stenosis of 75.5 to 22.3%. Percutaneous angioplasty and stenting were used in 58 cases; 8 patients were treated with stenting alone. Three patients (4.9%) developed neurological deficits mandating alteration or adjustment of endovascular technique or immediate postoperative management to avoid permanent sequelae. A total of 8 periprocedural complications occurred, 2 of which resulted in permanent neurological deficit. The overall mortality rate was 3.2%. CONCLUSIONS: Stenting of intracranial atherosclerosis performed under conscious sedation is associated with complication rates and effectiveness similar to historical rates for general anesthesia. Conscious sedation confers the additional benefit of continuous neurological assessment during the procedure.

Endoscopic cauterization of a symptomatic choroid plexus cyst at the foramen of Monro: case report.

OBJECTIVE: Choroid plexus cysts are common in the developing fetus, and although often persisting into adulthood, they rarely represent the underlying cause of symptomatic unilateral ventriculomegaly. The case presented here highlights both the diagnostic obscurity and endoscopic management of a choroid plexus cyst in a symptomatic patient. CLINICAL PRESENTATION: The patient is a 47-year-old white woman who presented with acute exacerbation of debilitating, diffuse, and postural headache, nausea, vomiting, early papilledema, and short-term memory loss. Cranial magnetic resonance imaging revealed an intraventricular mass obstructing the foramen of Monro on the left with ventriculomegaly. Cranial computed tomographic imaging demonstrated unilateral ventricular enlargement. INTERVENTION: During stereotactic endoscopic exploration, a choroid plexus cyst was evident at the foramen of Monro. Endoscopic cauterization of the cyst resulted in a decrease in the size of the left lateral ventricle, with complete relief of the patient's headaches and resolution of her memory loss. She remained headache free at the time of a 3-year follow-up evaluation after surgery. CONCLUSION: Choroid plexus cysts remain a diagnostic challenge; their presence should be sought out in the face of ventricular asymmetry and symptomatic hydrocephalus. Endoscopic ablation offers a minimally invasive treatment for the management of these lesions.