Preoperative diagnosis of Lhermitte-Duclos disease by magnetic resonance imaging. Case report.

Lhermitte-Duclos disease is a benign, presumably hamartomatous lesion of the cerebellum which presents clinically as a mass lesion. Pathologically, it consists of thickening of both the molecular and granular cell layers of the cerebral cortex which enlarges the folia but allows for preservation of the gyral pattern of the cerebellar cortex. Preoperative diagnosis with computerized tomography and other studies has not been possible, and even at surgery the diagnosis may be missed because of the preservation of the gyral pattern. The sensitivity of magnetic resonance imaging allows recognition of the cortical nature of the mass lesion, and especially the gyral pattern within the mass lesion, providing a diagnostic image which is unlikely to be confused with any other pathological process in the cerebellum. Preoperative diagnosis of Lhermitte-Duclos disease allows surgeons to plan an appropriate decompressive procedure.

Spontaneous arteriovenous fistula of the superficial temporal artery.

A case of a nontraumatic arteriovenous fistula of the superficial temporal artery, documented on selective external carotid arteriography, is described in a 42-year-old man who was successfully treated by complete surgical excision. The clinical features, differential diagnosis, and treatment of arteriovenous fistulas of the superficial temporal artery are reviewed.

Management of symptomatic deep venous thrombosis and pulmonary embolism on a neurosurgical service.

The authors present a retrospective analysis of the management of deep vein thrombosis (DVT) and pulmonary embolism (PE) in neurosurgical patients at the Massachusetts General Hospital from January, 1978, through June, 1982. There were 44 cases of DVT and 13 cases of PE. Management modalities included observation only, femoral vein ligation, inferior vena cava clipping, transvenous placement of an inferior vena cava filter or umbrella, and anticoagulation therapy. Six (75%) of eight patients with symptomatic DVT who were managed by observation alone had subsequent pulmonary emboli, and three (38%) died. Femoral vein ligation was followed by PE in one of four cases and led to significant leg swelling in two others. Neither observation alone nor femoral vein ligation can be recommended as routine management options. Partial inferior vena cava interruption with a De Weese clip, Kim-Ray Greenfield filter, or Mobin-Uddin umbrella all successfully prevented pulmonary emboli. The major problem associated with these methods was leg edema, which occurred in 47% of patients with clip placement, 25% with filter placement, and 21% with a Mobin-Uddin umbrella. Anticoagulation therapy was associated with a complication rate of 29% and a mortality rate of 15%. Fatal PE and paradoxical hypercoagulability with gangrene of a lower extremity were the causes of death. In one patient, hemorrhage into a glioblastoma occurred following discontinuation of anticoagulation therapy when the coagulation parameters were normal. The authors conclude that: 1) management with observation alone of patients with symptomatic DVT places the patient at risk for the development of life-threatening pulmonary emboli; 2) the safety and timing of therapeutic anticoagulation in postoperative neurosurgical patients or patients with tumors is unclear; and 3) partial interruption of the inferior vena cava with a transvenous filter successfully prevents PE and may represent a safer alternative to anticoagulation therapy.

Inadvertent middle cerebral artery embolism by a detachable balloon: management by embolectomy. Case report.

A case of middle cerebral artery embolism by a detachable intra-arterial balloon is presented. The balloon migrated after being detached in an effort to occlude the internal carotid artery proximal to an unclippable giant paraclinoid aneurysm. Volume expansion, induced hypertension, anticoagulation therapy, rapid middle cerebral artery embolectomy, and good collateral circulation are factors that may have contributed to the patient's complete recovery from hemiplegia.

Accessory nerve palsy following carotid endarterectomy. Report of two cases.

Two patients who had an accessory nerve palsy following carotid endarterectomy are presented. Both patients had high carotid bifurcations necessitating unusually high retraction and dissection. The ipsilateral accessory nerve was injured in the anterior cervical triangle in both cases. It is believed that vigorous lateral retraction of the superior aspect of the sternocleidomastoid muscle led to a stretch injury of the nerve. The symptoms completely resolved in both patients within 6 months.

Deep vein thrombosis and pulmonary emboli in neurosurgical patients: a review.

This review examines the incidence, natural history, diagnosis, prophylaxis, and management of deep vein thrombosis (DVT) and pulmonary embolism (PE) in neurosurgical patients. Recent studies estimate the incidence of postoperative DVT detected by fibrinogen scanning in neurosurgical patients to be 29% to 43%. Specific factors that enhance the risk of venous thromboembolism include previous DVT, surgery, immobilization, advanced age, obesity, limb weakness, heart failure, and lower extremity trauma. Clinical diagnosis of venous thromboembolism is unreliable but can be augmented by noninvasive screening tests such as iodine-125-fibrinogen scanning, Doppler ultrasonography, and impedance plethysmography. As prophylactic measures, mini-dose heparin and external pneumatic compression of the legs have decreased the incidence of DVT in clinical studies of neurosurgical patients. However, no prophylactic measure has been convincingly shown to prevent PE in neurosurgical patients. Thrombi involving the popliteal, deep femoral, and iliac veins appear most likely to cause significant PE. Anticoagulation therapy constitutes standard management of DVT and PE; however, in neurosurgical patients the potential for precipitating intracranial or intraspinal hemorrhage may necessitate vena caval interruption. This appears to be an effective alternative to anticoagulation.

Spontaneous spinal subarachnoid hemorrhage and subdural hematoma. Report of two cases.

Two patients with spontaneous spinal subarachnoid hemorrhage are presented to emphasize the clinical and radiological features of this uncommon illness. Both had severe back pain at the onset. One patient had a subdural hematoma that compressed the conus medullaris and cauda equina, and was drained percutaneously; the other had clots in the subarachnoid space. The cerebrospinal fluid showed a polymorphonuclear pleocytosis that simulated septic meningitis. Complete spinal angiography failed to reveal a cause for the hemorrhages.

Modified crossed leg raising test and sciatica.

A modification of the crossed leg raising test has been helpful in identifying patients with intervertebral disc disorders. Simultaneous flexion of the neck and elevation of the contralateral leg produced pain in the ipsilateral (presenting) sciatic notch in five patients with either free fragments or herniated disc found at operation. All patients were symptom-free postoperatively.

Modification of the Richmond subarachnoid screw for monitoring intracranial pressure. Technical note.

The authors describe a modification of a subarachnoid screw for monitoring intracranial pressure by hydrostatic coupling of the subarachnoid space to an external transducer. The device can be used in both children and adults and features more assured placement of the distal tip, increased stability, and enhanced safety on insertion.

Initial results of a clinical trial of Fluosol-DA 20 percent in acute cerebral ischemia.

We present three patients in whom Fluosol-DA 20 percent was administered in the presence of ischemic cerebral vascular disease. While transient improvement observed in two cases may have been related to Fluosol-DA administration it is premature to use these results to comment on the potential protective or therapeutic efficacy of Fluosol-DA in ischemic cerebral vascular disease. One patient progressively deteriorated neurologically during and after the infusion. Our initial impressions are limited to the observations that Fluosol-DA in doses of 20 ml/kg can be administered easily and without major effects on hemodynamic or pulmonary function. One patient had a transient leukopenia.