Atypical Intracerebral Developmental Venous Anomalies in Sturge-Weber Syndrome: A Case Series and Review of Literature.

BACKGROUND: Intracranial vascular abnormalities in Sturge-Weber syndrome, including leptomeningeal angiomatosis, anomalous cortical venous structures, and transmedullary developmental venous anomalies, are well recognized. Prominent vascular flow voids on T2-weighted magnetic resonance imaging (MRI) are occasionally identified in patients with Sturge-Weber syndrome, raising concern of arteriovenous malformations, a congenital high-flow vascular malformation with a risk of bleeding. METHODS: We report four patients with prominent flow voids on conventional MRI that suggested high-flow lesions. RESULTS: Diagnostic evaluation was performed with cerebral angiography in one patient and with a combination of magnetic resonance angiography and magnetic resonance venography in three patients. In all four patients, the conventional MRI-identified lesions represented prominent developmental venous anomalies and not arteriovenous malformations. CONCLUSIONS: This series highlights that developmental venous anomalies may appear in individuals with Sturge-Weber syndrome as unusually large and seemingly high-flow lesions on MRI. Noninvasive imaging with magnetic resonance angiography and magnetic resonance venography can be used in the management of such patients for further characterization of these vascular structures.

Artificial Neural Network Computer Tomography Perfusion Prediction of Ischemic Core.

Background and Purpose- Computed tomography perfusion (CTP) is a useful tool in the evaluation of acute ischemic stroke, where it can provide an estimate of the ischemic core and the ischemic penumbra. The optimal CTP parameters to identify the ischemic core remain undetermined. Methods- We used artificial neural networks (ANNs) to optimally predict the ischemic core in acute stroke patients, using diffusion-weighted imaging as the gold standard. We first designed an ANN based on CTP data alone and next designed an ANN based on clinical and CTP data. Results- The ANN based on CTP data predicted the ischemic core with a mean absolute error of 13.8 mL (SD, 13.6 mL) compared with diffusion-weighted imaging. The area under the receiver operator characteristic curve was 0.85. At the optimal threshold, the sensitivity for predicting the ischemic core was 0.90 and the specificity was 0.62. Combining CTP data with clinical data available at time of presentation resulted in the same mean absolute error (13.8 mL) but lower SD (12.4 mL). The area under the curve, sensitivity, and specificity were 0.87, 0.91, and 0.65, respectively. The maximal Dice coefficient was 0.48 in the ANN based on CTP data exclusively. Conclusions- An ANN that integrates clinical and CTP data predicts the ischemic core with accuracy.

Optimal Computed Tomographic Perfusion Scan Duration for Assessment of Acute Stroke Lesion Volumes.

BACKGROUND AND PURPOSE: The minimal scan duration needed to obtain reliable lesion volumes with computed tomographic perfusion (CTP) has not been well established in the literature. METHODS: We retrospectively assessed the impact of gradual truncation of the scan duration on acute ischemic lesion volume measurements. For each scan, we identified its optimal scan time, defined as the shortest scan duration that yields measurements of the ischemic lesion volumes similar to those obtained with longer scanning, and the relative height of the fitted venous output function at its optimal scan time. RESULTS: We analyzed 70 computed tomographic perfusion scans of acute stroke patients. An optimal scan time could not be determined in 11 scans (16%). For the other 59 scans, the median optimal scan time was 32.7 seconds (90th percentile 52.6 seconds; 100th percentile 68.9 seconds), and the median relative height of the fitted venous output function at the optimal scan times was 0.39 (90th percentile 0.02; 100th percentile 0.00). On the basis of a linear model, the optimal scan time was T0 plus 1.6 times the width of the venous output function (P<0.001; R2=0.49). CONCLUSIONS: This study shows how the optimal duration of a computed tomographic perfusion scan relates to the arrival time and width of the contrast bolus. This knowledge can be used to optimize computed tomographic perfusion scan protocols and to determine whether a scan is of sufficient duration. Provided a baseline (T0) of 10 seconds, a total scan duration of 60 to 70 seconds, which includes the entire downslope of the venous output function in most patients, is recommended.

Thermal properties of contemporary bipolar systems using infrared imaging.

BACKGROUND: Bipolar coagulation has enhanced the capabilities and safety profile of contemporary neurosurgery and has become indispensable in the neurosurgical armamentarium. Nevertheless, significant heat transfer issues remain to be resolved before it can achieve the status of minimal risk. METHODS: The Codman irrigating forceps, Codman ISOCOOL forceps, and Ellman bipolar forceps, powered by either Synergy or Ellman generators set at various power levels, were compared to investigate the combinations that would allow for the lowest rate of heat transfer. Using an infrared camera and ThermaGRAM imaging software, the temperature was calculated and used to estimate the degree of heat transfer. RESULTS: Codman ISOCOOL forceps powered the Ellman Surgitron generator showed the greatest dissipation (at mid-power, the luminance decreased from 250 units to 80 units within 60 seconds) and the least production of heat after activation. Codman ISOCOOL forceps powered by the Codman SYNERGY MALIS generator showed less heat dissipation (at mid-power, the luminance decreased from 250 units to 195 units within 60 seconds) than the Ellman forceps and Ellman Surgitron generator combination (at mid-power, the luminance decreased from 250 units to 125 units within 60 seconds). CONCLUSIONS: These data suggest that the incorporation of the Ellman Surgitron Generator can result in the reduction of thermal transfer with conventional bipolar forceps compared with other generators. The combination with Codman ISOCOOL forceps can maximize the potential safety associated with bipolar coagulation. With regard to the use of comarketed pairs of forceps and generators, the combination of Ellman Surgitron Generator and Ellman bipolar forceps provided the best thermal profile.

Palliative epilepsy surgery in Aicardi syndrome: a case series and review of literature.

PURPOSE: Aicardi syndrome (AS) is a severe neurodevelopmental disorder characterized by the triad of seizures, agenesis of corpus callosum, and chorioretinal lacunae. Seizures in AS are typically frequent, of various types, and refractory to medical therapy. Optimal treatment of seizures in AS remains undetermined. METHODS: We report a series of four patients with Aicardi syndrome who underwent surgical management of their epilepsy including two with corpus callosotomy (CC) of a partial corpus callosum and three with vagus nerve stimulator implantation. RESULTS: Seizure outcome was variable and ranged from near complete resolution of seizures to worsening of seizure profile. The most favorable seizure outcome was seen in a patient with partial agenesis of the corpus callosum treated with CC. CONCLUSIONS: Seizure outcome following CC or vagus nerve stimulation in patients with Aicardi syndrome is variable. Although palliative epilepsy surgery may result in improvement in the seizure profile in some patients, studies on larger patient cohorts are needed to identify the precise role that surgery may play in the multidisciplinary approach to controlling seizures in Aicardi syndrome.

Outcomes after anterior or complete corpus callosotomy in children.

BACKGROUND: Corpus callosotomy (CC) is a valuable palliative surgical option for children with medically refractory epilepsy due to generalized or multifocal cortical seizure onset. OBJECTIVE: To investigate the extent of CC resulting in optimal seizure control in a pediatric patient population and to evaluate the modification of seizure profile after various CC approaches. METHODS: The records of 58 children (3-22 years of age at the time of surgery) with medically refractory epilepsy who underwent CC between 1995 and 2011 were retrospectively reviewed. RESULTS: Anterior two thirds callosotomy resulted in resolution of absence (P = .03) and astatic (P = .03) seizures, whereas anterior two thirds callosotomy followed by second-stage completion resulted in resolution of generalized tonic-clonic (GTC) (P = .03), astatic (P = .005), and myoclonic (P = .03) seizures in addition to a trend toward resolution of absence seizures (P = .08). Single-stage upfront complete callosotomy resulted in resolution of absence (P = .002), astatic (P < .0001), myoclonic (P = .007), and complex partial (P = .008) seizures in addition to a trend toward resolution of GTC (P = .06). In comparing a composite of subjects who underwent anterior two thirds callosotomy alone or 2-stage complete callosotomy before the second stage to complete the callosotomy with subjects who underwent upfront complete CC, a more favorable outcome was found in those with the upfront complete CC (P = .02). CONCLUSION: Single-stage upfront complete callosotomy is effective in relieving a broader spectrum of seizure types than anterior two thirds callosotomy or 2-stage complete callosotomy in children. The advantages of single-stage complete callosotomy must be weighed against the potentially higher risk of neurological and operative complications.

Concussions in soccer: a current understanding.

OBJECTIVE: Traumatic brain injury (TBI) is a significant public health problem in the United States, with approximately 1.5-2 million TBIs occurring each year. However, it is believed that these figures underestimate the true toll of TBI. Soccer is the most popular sport in the world and has a following of millions in the United States. Soccer is a sport not traditionally identified as high-risk for concussions, yet several studies have shown that concussion rates in soccer are comparable to, and often exceed those of, other contact sports. As many as 22% of all soccer injuries are concussions. METHODS: Soccer is a sport not traditionally identified as high risk for concussions, yet several studies have shown that concussion rates in soccer are comparable to, and often exceed those of, other contact sports. As many as 22% of all soccer injuries are concussions. Head injury during soccer is usually the result of either "direct contact" or contact with the ball while "heading" the ball. Relationships between the number of headers sustained in a single season and the degree of cognitive impairment (attention and visual/verbal memory) have been demonstrated. It is also likely that multiple concussions may cause cumulative neuropsychologic impairment in soccer players. RESULTS: Although our understanding of risk factors for sports-related concussions is far from complete, there is great potential for prevention in sports-related concussions. Several measures must be taken to avert the development of concussions in soccer and, when they take place, reduce their effects. These include the development and testing of effective equipment during play, the maintenance of regulatory standards for all such equipment, educating young athletes on the safe and appropriate techniques used during play, and strict adherence to the rules of competition. CONCLUSIONS: In spite of such preventive measures, concussions in soccer will continue to occur. Considering the frequency of concussions in soccer, the serious sequelae of these concussions, and because almost half of concussed soccer players were noncompliant with recommended American Academy of Neurology return-to-play guidelines, further measures must be taken to protect players, in addition to understanding those criteria that result in removing an injured player from competition and the steps by which to safely return an athlete to competition after injury.

Characterization of the supplementary motor area syndrome and seizure outcome after medial frontal lobe resections in pediatric epilepsy surgery.

BACKGROUND: In adults, resection of the medial frontal lobe has been shown to result in supplementary motor area (SMA) syndrome, a disorder characterized by transient motor impairment. Studies examining the development of SMA syndrome in children, however, are wanting. OBJECTIVE: To characterize the development of SMA syndrome and to analyze seizure outcomes after surgery in the medial frontal lobe for medically intractable epilepsy. METHODS: Thirty-nine patients with medically intractable epilepsy who underwent surgery in the medial frontal lobe were reviewed retrospectively. The progression of neurological impairment and seizure outcome after surgery was recorded, and the extent of cortex resected was analyzed. RESULTS: After resection in the region of the SMA, 23 patients (59%) developed postoperative neurological impairment; 17 (74%) were identified as SMA syndrome. No neurological impairment was found after surgery in 16 patients (41%). Six patients (15%) experienced permanent neurological impairment. The majority of patients (82%) who developed SMA syndrome had resolution of their symptoms by 1 month postoperatively. Preoperative magnetic resonance imaging finding of lesional cases was associated with a significantly decreased likelihood of developing SMA syndrome (P = .02). Seizure outcome was favorable after surgery in most patients. CONCLUSION: Surgery for medically intractable epilepsy in the region of the medial frontal cortex is effective and associated with reversible neurological impairment in children. All patients had resolution of their SMA syndrome by 6 months postoperatively.