Mechanical thrombectomy for acute stroke in childhood: how much does restricted diffusion matter?

Mechanical thrombectomy holds promise for children with large cerebral arterial occlusions, although there are few reports in this population. We report a case of retrievable stent-assisted mechanical thrombectomy in a 5-year-old with basilar artery occlusion, despite late presentation and extensive initial diffusion-weighted imaging (DWI) restriction. This resulted in successful Thrombolysis in Cerebral Infarction 2B reperfusion and excellent clinical outcome. At 6-week follow-up he was completely back to baseline with no residual deficits (pediatric stroke outcome measure=0, modified Rankin scale=0). At 3-month follow-up the patient has not had any recurrent stroke or concern for stroke-like symptoms. We review the literature on mechanical thrombectomy and DWI changes in acute stroke in early to middle childhood (<12 years old).

Mechanical thrombectomy for acute stroke in childhood: how much does restricted diffusion matter?

Mechanical thrombectomy holds promise for children with large cerebral arterial occlusions, although there are few reports in this population. We report a case of retrievable stent-assisted mechanical thrombectomy in a 5-year-old with basilar artery occlusion, despite late presentation and extensive initial diffusion-weighted imaging (DWI) restriction. This resulted in successful Thrombolysis in Cerebral Infarction 2B reperfusion and excellent clinical outcome. At 6-week follow-up he was completely back to baseline with no residual deficits (pediatric stroke outcome measure=0, modified Rankin scale=0). At 3-month follow-up the patient has not had any recurrent stroke or concern for stroke-like symptoms. We review the literature on mechanical thrombectomy and DWI changes in acute stroke in early to middle childhood (<12 years old).

Decreased Rate of CSF Leakage Associated with Complete Reconstruction of Suboccipital Cranial Defects.

Background Cerebrospinal fluid (CSF) leakage represents a major source of morbidity following microvascular decompression (MVD) surgery. The objective of this study was to retrospectively assess whether complete versus incomplete reconstruction of the suboccipital cranial defect influences the incidence of CSF leakage following MVD. Methods We reviewed the charts of 100 patients who consecutively underwent MVD for trigeminal neuralgia by two attending neurosurgeons between July 2004 and April 2010. Operative variables including incomplete or complete calvarial reconstruction, primary dural closure or dural closure with adjunct, and use of lumbar drainage were recorded. The effect of complete calvarial reconstruction on the incidence of postoperative CSF leakage was examined using a multivariate logistic regression model. Results Of the 36 patients whose wound closure was reconstructed with a complete cranioplasty, 2 (5.6%) patients experienced a postoperative CSF leak. Of the 64 patients whose wound closure was augmented with an incomplete cranioplasty, 15 (23.4%) experienced a postoperative CSF leak. There was suggestive but inconclusive evidence that the risk of CSF leakage following MVD was smaller with complete reconstruction of calvarial defect than with incomplete reconstruction (two-sided p value = 0.059), after accounting for age, dural closure method, use of lumbar drainage, and previous MVD. Conclusion Complete reconstruction of the suboccipital cranial defect decreases the risk of CSF leakage.

Pediatric cerebellar pilomyxoid-spectrum astrocytomas.

OBJECT: Pediatric cerebellar astrocytomas with pilomyxoid features include classic pilomyxoid astrocytomas (PMAs) and intermediate pilomyxoid tumors (IPTs). Since the original description of PMA in 1999, most reports in the literature have described PMAs arising from the hypothalamic/chiasmatic region. To the authors' knowledge, PMAs arising from the posterior fossa have not been discussed in the neurosurgical literature. Intermediate pilomyxoid tumors, or tumors with pathological features of both pilocytic astrocytoma (PA) and PMA, have only recently been described. In this article, the authors present 2 cases that fall within the spectrum of pediatric cerebellar PMA-including a classic PMA and an intermediate pilomyxoid tumor. The authors compare the radiological presentation, surgical results, and postoperative course to findings in a cohort of 15 patients with cerebellar PAs. METHODS: Between 2003 and 2010, 2 patients with pilomyxoid-spectrum astrocytomas underwent treatment at Vanderbilt Children's Hospital. One was a 22-month-old girl who presented with progressive gait disturbance and falls. The other was a 4-year-old girl who presented with ataxia and generalized weakness. In a retrospective review of pediatric cerebellar neoplasms resected by the senior author during this period, these tumors comprised 4% of cerebellar neoplasms and approximately 10% of cerebellar glial neoplasms. RESULTS: Both patients were treated with midline suboccipital craniotomy for resection. In both cases, tumor invasion anteriorly into the brainstem prevented gross-total resection. the patient in Case 1 was placed on chemotherapy following pathological diagnosis and later developed definitive evidence of leptomeningeal dissemination (LD) 3 years after the operation. The patient in Case 2 was placed on chemotherapy after exhibiting progressive evidence of local recurrence (findings were negative for LD) 12 months following resection. CONCLUSIONS: Pediatric patients with cerebellar pilomyxoid-spectrum astrocytomas appear to suffer higher rates of local recurrence and LD than pediatric patients with cerebellar PAs.

Microvascular decompression: salient surgical principles and technical nuances.

Trigeminal neuralgia is a disorder associated with severe episodes of lancinating pain in the distribution of the trigeminal nerve. Previous reports indicate that 80-90% of cases are related to compression of the trigeminal nerve by an adjacent vessel. The majority of patients with trigeminal neuralgia eventually require surgical management in order to achieve remission of symptoms. Surgical options for management include ablative procedures (e.g., radiosurgery, percutaneous radiofrequency lesioning, balloon compression, glycerol rhizolysis, etc.) and microvascular decompression. Ablative procedures fail to address the root cause of the disorder and are less effective at preventing recurrence of symptoms over the long term than microvascular decompression. However, microvascular decompression is inherently more invasive than ablative procedures and is associated with increased surgical risks. Previous studies have demonstrated a correlation between surgeon experience and patient outcome in microvascular decompression. In this series of 59 patients operated on by two neurosurgeons (JSN and PEK) since 2006, 93% of patients demonstrated substantial improvement in their trigeminal neuralgia following the procedure--with follow-up ranging from 6 weeks to 2 years. Moreover, 41 of 66 patients (approximately 64%) have been entirely pain-free following the operation. In this publication, video format is utilized to review the microsurgical pathology of this disorder. Steps of the operative procedure are reviewed and salient principles and technical nuances useful in minimizing complications and maximizing efficacy are discussed.

No evidence for association of the MDM2-309 T/G promoter polymorphism with prostate cancer outcomes.

OBJECTIVES: Mouse double-minute 2 (MDM2) SNP309 polymorphism (T>G) has been correlated with an increased risk of cancer in multiple tumor types. MDM2 overexpression has shown to be weakly associated with distant tumor metastases, and down-regulation of MDM2 via antisense oligonucleotides in vitro has resulted in the radiosensitization of prostate cancer cell lines. Based on these results, we decided to evaluate the role of MDM2 SNP309 in the context of histopathologic parameters and clinical outcomes in prostate cancer tumors. MATERIALS AND METHODS: The population consisted of 212 consecutive prostate cancer patients who underwent radical prostatectomy between 1997 and 1999 at Vanderbilt University Medical Center. Two hundred eight of the samples were successfully genotyped for the MDM2 SNP309 polymorphism. Correlations between the polymorphism, recurrence, and survival data were analyzed using univariate and multivariate genetic models. RESULTS: The only prognostic factor predictive of overall survival in our study was Gleason score (P<0.005). Using χ(2) analysis, we determined that the MDM2 SNP309 polymorphism had no significant association with race (P=0.7512), patient's age at diagnosis (P=0.6820), pre-prostatectomy PSA level (P=0.8606), Gleason's score (P=0.4839), surgical margin status (P=1.0000), extracapsular extension (P=0 .6175), and disease stage (P=0.4945). In addition, there was no significant difference in 3-year recurrence-free survival (P=0.218), or 8-year overall survival (P=0.376). CONCLUSIONS: Our study finds no evidence for association of the MDM2 SNP309 polymorphism with clinicopathologic variables, recurrence risk, and overall survival outcome in prostate cancer.