Brachial plexus injury management in military casualties: who, what, when, why, and how.

The Global War on Terrorism has achieved an unprecedented 90% casualty survival rate because of far forward surgical support, rapid transport, and body armor. Despite the remarkable protection body armor affords, peripheral nerve injuries continue to occur. The brachial plexus in particular is still susceptible to penetrating trauma through the axilla as well as blunt mechanisms. We report 1,818 individuals with reported cases of peripheral nerve injury, 97 of which had brachial plexus injury incident from Operation Iraqi Freedom and Operation Enduring Freedom. We suspect that true prevalence is higher as initial focus on vascular and orthopedic reconstruction in complex shoulder injuries may overlook brachial plexus lesions. Accordingly, emergency physicians, general and orthopedic trauma surgeons, and vascular surgeons should all consider the possibility of brachial plexus and other peripheral nerve injury for early and appropriate referral to surgeons (plastic, orthopedic, or neurosurgical) for further evaluation and reconstruction. The latter group should be familiar with appropriate modern diagnostic and initial as well as salvage therapeutic options.

Gamma knife surgery for skull base meningiomas.

OBJECT: Skull base meningiomas are challenging tumors owing in part to their close proximity to important neurovascular structures. Complete microsurgical resection can be associated with significant morbidity, and recurrence rates are not inconsequential. In this study, the authors evaluate the outcomes of skull base meningiomas treated with Gamma Knife surgery (GKS) both as an adjunct to microsurgery and as a primary treatment modality. METHODS: The authors performed a retrospective review of a prospectively compiled database detailing the outcomes in 255 patients with skull base meningiomas treated at the University of Virginia from 1989 to 2006. All patients had a minimum follow-up of 24 months. The group comprised 54 male and 201 female patients, with a median age of 55 years (range 19-85 years). One hundred nine patients were treated with upfront radiosurgery, and 146 patients were treated with GKS following resection. Patients were assessed clinically and radiographically at routine intervals following GKS. Factors predictive of new neurological deficit following GKS were assessed via univariate and multivariate analysis, and Kaplan-Meier analysis and Cox multivariate regression analysis were used to assess factors predictive of tumor progression. RESULTS: Meningiomas were centered over the cerebellopontine angle in 43 patients (17%), the clivus in 40 (16%), the petroclival region in 28 (11%), the petrous region in 6 (2%), and the parasellar region in 138 (54%). The median duration of follow-up was 6.5 years (range 2-18 years). The mean preradiosurgery tumor volume was 5.0 cm(3) (range 0.3-54.8 cm(3)). At most recent follow-up, 220 patients (86%) displayed either no change or a decrease in tumor volume, and 35 (14%) displayed an increase in volume. Actuarial progression-free survival at 3, 5, and 10 years was 99%, 96%, and 79%, respectively. In Cox multivariate analysis, pre-GKS covariates associated with tumor progression included age greater then 65 years (HR 3.41, 95% CI 1.63-7.13, p = 0.001) and decreasing dose to tumor margin (HR 0.90, 95% CI 0.80-1.00, p = 0.05). At most recent clinical follow-up, 230 patients (90%) demonstrated no change or improvement in their neurological condition and the condition of 25 patients had deteriorated (10%). In multivariate analysis, the factors predictive of new or worsening symptoms were increasing duration of follow-up (OR 1.01, 95% CI 1.00-1.02, p = 0.015), tumor progression (OR 2.91, 95% CI 1.60-5.31, p < 0.001), decreasing maximum dose (OR 0.90, 95% CI 0.84-0.97, p = 0.007), and petrous or clival location versus parasellar, petroclival, and cerebellopontine angle location (OR 3.47, 95% CI 1.23-9.74, p = 0.018). CONCLUSIONS: Stereotactic radiosurgery offers a high rate of tumor control and neurological preservation in patients with skull base meningiomas. After radiosurgery, better outcomes were observed for those receiving an optimal radiosurgery dose and harboring tumors located in a cerebellopontine angle, parasellar, or petroclival location.

Neurocognitive changes in pituitary adenoma patients after gamma knife radiosurgery: a preliminary study.

OBJECTIVE: We evaluated the effects of gamma-knife radiosurgery (GKRS) on the cognitive functioning of patients with a pituitary adenoma. METHODS: A total of 14 patients with pituitary adenomas were enrolled in this neurocognitive study. Nine patients had Cushing disease, and five had nonfunctioning pituitary adenomas. Five patients underwent GKRS for their pituitary adenomas. Other treatment modalities included transsphenoidal resection and conservative management. Comparisons were made between treatment groups and between those with Cushing disease versus those with a nonfunctioning adenoma by the use of psychometric tests of general intellectual functioning, memory, and current mood state. These tests were the Symptom Checklist 90 Revised, Wechsler Test of Adult Reading, Wechsler Memory Scale-third edition, selected subtests of the Wechsler Adult Intelligence Scale-third edition, and the Delis-Kaplan Executive Function System. RESULTS: When analyzed collectively, the patient group showed deficits in immediate memory (t=-2.70, P=0.02) and high levels of psychological distress (46% of patients) in the presence of intact general intellectual functioning. No neurocognitive differences were found between the GKRS treated group versus participants not treated with GKRS (t≤0.70, P≥0.39). Similarly, no appreciable neurocognitive differences were demonstrated between those with nonfunctioning adenomas as compared with those with Cushing disease (t≤1.56, P≥0.15). CONCLUSIONS: We found no evidence that GKRS impairs the neurocognitive functioning of patients with pituitary disease above any impairment caused by the disease itself. Further studies will require approximately 20 patients in each comparison group to confirm this result.