Complications of invasive video-EEG monitoring with subdural grid electrodes.

OBJECTIVE: To evaluate the risk factors, type, and frequency of complications during video-EEG monitoring with subdural grid electrodes. METHODS: The authors retrospectively reviewed the records of all patients who underwent invasive monitoring with subdural grid electrodes (n = 198 monitoring sessions on 187 patients; median age: 24 years; range: 1 to 50 years) at the Cleveland Clinic Foundation from 1980 to 1997. RESULTS: From 1980 to 1997, the complication rate decreased (p = 0.003). In the last 5 years, 19/99 patients (19%) had complications, including two patients (2%) with permanent sequelae. In the last 3 years, the complication rate was 13.5% (n = 5/37) without permanent deficits. Overall, complications occurred during 52 monitoring sessions (26.3%): infection (n = 24; 12.1%), transient neurologic deficit (n = 22; 11.1%), epidural hematoma (n = 5; 2.5%), increased intracranial pressure (n = 5; 2.5%), and infarction (n = 3; 1.5%). One patient (0.5%) died during grid insertion. Complication occurrence was associated with greater number of grids/electrodes (p = 0.021/p = 0.052; especially >60 electrodes), longer duration of monitoring (p = 0.004; especially >10 days), older age of the patient (p = 0.005), left-sided grid insertion (p = 0.01), and burr holes in addition to the craniotomy (p = 0.022). No association with complications was found for number of seizures, IQ, anticonvulsants, or grid localization. CONCLUSIONS: Invasive monitoring with grid electrodes was associated with significant complications. Most of them were transient. Increased complication rates were related to left-sided grid insertion and longer monitoring with a greater number of electrodes (especially more than 60 electrodes). Improvements in grid technology, surgical technique, and postoperative care resulted in significant reductions in the complication rate.

Surgical management of pediatric tumor-associated epilepsy.

Brain tumors are a common cause of seizures in children. Early surgical treatment can improve seizure outcome, but controversy exists regarding the most appropriate type of surgical intervention. Some studies suggest tumor resection alone is sufficient, while others recommend mapping and resection of the surrounding epileptogenic foci to optimize seizure outcome. To address this issue, we reviewed the charts of 34 pediatric patients aged 18 months to 20 years with medically intractable epilepsy and primary brain tumors. The average age at operation was 12.6 years, and patients had seizures for an average of 6.4 years. The majority of tumors were located in the temporal lobe. Seventeen patients, because of tumor location near an eloquent area, underwent extraoperative mapping using subdural electrode grids prior to definitive tumor resection. Fourteen of these patients had a gross total tumor resection, yet only two had a distinct zone of ictal onset identified and resected. The remaining 17 patients had tumors either in the nondominant hemisphere or far removed from speech-sensitive areas, and therefore did not undergo extraoperative subdural electroencephalograph mapping. Fourteen of these patients also had a gross total tumor resection, while none had intraoperative electrocorticography to guide the resection of additional nontumoral tissue. Overall, of the 28 patients treated with a gross total tumor resection, 24 (86%) are seizure free, while the other four are significantly improved. Of the six patients who had a subtotal tumor removal, five have persistent seizures. The mean follow-up was 3.6 years. We conclude that in children and adolescents, completeness of tumor resection is the most important factor in determining seizure outcome. The routine mapping and resection of epileptogenic foci might not be necessary in the majority of patients. As a corollary, the use of subdural electrode grids in pediatric patients with tumor-associated epilepsy should be limited to cases requiring extraoperative cortical stimulation for localization of nearby eloquent cortex.

Manual vs robotically assisted laparoscopic surgery in the performance of basic manipulation and suturing tasks.

OBJECTIVE: To compare the surgical performance of manual and robotically assisted laparoscopic instruments on basic maneuvers and intracorporeal suturing in inanimate models. DESIGN: A set of laparoscopic tasks was used to evaluate basic endoscopic movements and intracorporeal suturing: positioning a cylinder on a Peg-Board, dropping beads into receptacles, running a 25-cm rope, and capping a hypodermic needle. Intracorporeal knot tying and running a suture through predetermined points were evaluated separately. The sutures used for these tasks were 2-0 and 4-0 silk and 6-0 and 7-0 polypropylene. PARTICIPANTS: Twenty surgeons completed the set of laparoscopic tasks manually and then with a robotically assisted system. None had used the robotic system before. MAIN OUTCOME MEASURES: Time required to complete the tasks and the precision in performing them. RESULTS: The robotic system accurately reproduced the movements of the surgeons and filtered their hand tremors efficiently. In the basic tasks, operative times were significantly longer for the robotic system (P<.001). In the suturing tasks, operative times were longer with the use of the robotic system for sutures sizes 2-0 and 4-0 (P<.001). However, time differences were not significant for suture sizes 6-0 and 7-0 (P> or =.07). Precision measurements were similar for all tasks using the manual instruments and the robotically assisted system. No significant differences were found between the performance of advanced laparoscopic surgeons and laparoscopic fellows. CONCLUSIONS: Laparoscopic maneuvering and suturing is faster and just as precise when performed manually as when performed with the prototype robotic system. These differences in speed are inversely proportional to the size of the suture. Future generations of the robotic system may eliminate these differences.

Differential ventricular expansion in hydrocephalus.

In the large canine model of acquired obstructive hydrocephalus that we have developed recently, computer-assisted 3-dimensional morphometry has been performed on T1-weighted Spin Echo MRI images from adult dogs before and after the induction of hydrocephalus. To date, 7 hydrocephalic animals have been analyzed that survived 7-83 days (median = 54) after receiving injections of cyanoacrylate glue into the anterior fourth ventricle. Measurements were obtained from lateral, 3rd, and 4th ventricles. The volumes of the left and right lateral ventricles were symmetrical before and after induction. Mean lateral ventricle volume increased 424% from a baseline of 0.63 cc to a post-induction value of 3.30 cc (p < 0.01 with unpaired t-test). In contrast, the 3rd ventricle expanded 187% from a mean of 0.15 cc to 0.43 cc (p < 0.05). The combined volume of the lateral and 3rd ventricles increased 369% from a mean of 0.78 cc to 3.69 cc (p < 0.01). Evans' ratios, which are used routinely in the clinical setting, were also obtained from linear measurements of the lateral ventricle width divided by brain width at the level of the foramen of Monro. These values exhibited only a 94% increase from mean baseline ratios of 0.17 to post-induction ratios of 0.33 (p < 0.05). These findings indicate that in mechanically-induced obstructive hydrocephalus the relative expansion of the lateral ventricles is greater than that of the 3rd ventricle. In addition, volumetric measurements of the lateral and 3rd ventricles suggest that the extent of ventriculomegaly is 3-4 times greater than estimated by Evans' ratios.

Viable neurons with luxury perfusion in hydrocephalus.

A woman with hydrocephalus due to aqueductal stenosis had functional imaging of cerebral perfusion and metabolism to demonstrate the effects of endoscopic third ventriculostomy--a new form of internal surgical shunting. Technetium-99m-ECD SPECT and 18F-FDG PET showed regional luxury perfusion at the left frontal region. Three months after a successful third ventriculostomy, a repeated imaging of cerebral perfusion and metabolism showed resolution of luxury perfusion and global improvement of both perfusion and metabolism. This concurred with postoperative clinical improvement. The paired imaging of cerebral perfusion and metabolism provides more information than just imaging perfusion or metabolism. Thus, the detection of perfusion and metabolism mismatch may open a new window of opportunity for surgical intervention.

Prevention of chronic cerebral vasospasm in dogs with milrinone.

OBJECTIVE: Delayed cerebral ischemia resulting from vasospasm is a major cause of morbidity and death in patients with aneurysmal subarachnoid hemorrhage. Milrinone, because it inhibits Type IV cyclic adenosine monophosphate-specific phosphodiesterase enzyme in both cardiac and vascular smooth muscle, is a powerful inotrope and vasodilator, but it has little effect on heart rate or blood pressure. Because of these properties, milrinone is an attractive potential therapy after subarachnoid hemorrhage. The purpose of the present study was to investigate the effect of milrinone on chronic experimental cerebral vasospasm. METHODS: A double-hemorrhage canine model of vasospasm was used to study the efficacy of milrinone. Angiographic vasospasm and systemic hemodynamics were compared in a treatment group of animals that received a loading dose of milrinone (0.05 mg/kg, intravenously) and then slow-release (0.05 microgram/kg/min) milrinone pellets (n = 10) and a control group that received placebo pellets (n = 9), over an 8-day period after the initial subarachnoid hemorrhage. The hemorrhage was created by injection of 4 ml of autologous, nonheparinized, arterial blood into the cisterna magna on Days 1 and 3. Hemodynamic measurements, including cardiac output determinations, were made on Days 0, 1, 3, 6, and 8 with a pulmonary artery catheter, and angiographic vasospasm was assessed on Day 8 by comparison with baseline angiograms. RESULTS: Treatment with milrinone caused no significant changes in systemic hemodynamics. Angiographic vasospasm, however, was significantly reduced in the Day 8 angiograms for the treated group, compared with the control group (98.28 +/- 14.06 and 67.89 +/- 13.06% of original vessel cross-sectional area, respectively; P < 0.001). CONCLUSION: Milrinone is effective in preventing chronic cerebral vasospasm in a canine model of experimental chronic cerebral vasospasm. This effect is independent of changes in systemic hemodynamics. Milrinone and related drugs warrant further investigation for the treatment of cerebral vasospasm.

Robotic surgical instruments for dexterity enhancement in thoracoscopic coronary artery bypass graft.

OBJECTIVES: Endoscopically sutured vascular anastomoses are complex, time consuming, and require great dexterity. We decided to evaluate performance enhancement using a robotic device to create sutured coronary artery bypass anastomoses with endoscopic techniques in a plastic model. METHODS: Seven coronary artery bypass anastomoses were endoscopically created in a plastic model using a robotic enhancement technology (Computer Motion, Goleta, CA). Anastomoses were created with a single running suture (7-0 monofilament). Our endpoints were operative time, intraoperative incidents, stability and dexterity of the robotic system, surgeon's fatigue, and anastomotic patency. RESULTS: Operative time was 46+/-12 min (mean+/-SD). There were no intraoperative incidents. Patency was confirmed in all anastomoses. The system's stability and dexterity were high. Surgeon's fatigue was mild. CONCLUSION: The use of robotic enhancement technology leads to an efficient performance of sutured coronary artery bypass anastomoses in a plastic model. The robotic device enhances dexterity, precision, and reduces surgeon's fatigue while preserving the quality of hand suturing.

Split calvarial bone graft in cranio-orbital sphenoid wing reconstruction.

Sphenoid wing defects of the posterior orbit and frontal and middle cranial fossae, secondary to tumor ablation, create difficulties in orbital and cranial base reconstruction. Autogenous split calvarial bone grafts harvested at the time of neurosurgical tumor ablation were used to reconstruct sphenoid wing defects in nine patients between July 1983 and January 1993. Meningioma is the most common tumor resected in this series, followed by fibrous dysplasia. Patient follow-up ranged from 1 to 5 years with a mean of 3 years. Calvarial bone grafting was performed to restore continuity of frontal bone, supraorbital ridge, orbital roof, and lateral wall and floor. All patients demonstrating proptosis showed either complete resolution or significant improvement postoperatively by exophthalmometry. Postoperative pulsatile exophthalmos occurred transiently in one patient but resolved spontaneously. Postoperative diplopia occurred in two patients, which subsequently resolved within 6 weeks. There were no incidents of postoperative osteomyelitis or bone graft loss within the reported postoperative period. Conventional and three-dimensional computed axial tomographic scans did not demonstrate bony resorption resulting in structural instability in any of the cases with this reconstructive method.

Antibiotic penetration into cervical discs.

Antibiotics are frequently prophylactically administered in surgical procedures to reduce the incidence of infection. The penetration of antibiotics into lumbar discs has been studied with mixed results, but penetration into cervical discs has not been reviewed. In this study, we examined the penetration of two commonly used antibiotics, oxacillin and cefazolin, into cervical discs. Eighteen patients with a total of 30 discs removed were studied. Two groups, each consisting of four patients with five discs removed, received either 1 g of oxacillin or 1 g of cefazolin by a single, preoperative intravenous infusion. Two other groups, each consisting of five patients with 10 discs removed, received either 2 g of oxacillin or 2 g of cefazolin, also by a single, preoperative intravenous infusion. A blood specimen, from which serum antibiotic levels were determined, was obtained from each patient simultaneously with each discectomy. The time interval between the antibiotic infusion and discectomy/phlebotomy was also recorded. Antibiotic levels were detected in all discs removed but were quantifiable in only 12. Nine of these 12 had been exposed to cefazolin. Of these nine discs, one was from a patient who had received 1 g whereas the other eight were from patients who had received 2 g of cefazolin. This represents 80% of the removed discs exposed to 2 g of cefazolin (10 discs total) and 20% exposed to 1 g (5 discs total). The remaining three discs with quantifiable antibiotic levels had been exposed to 2 g of oxacillin, which represents 30% of the discs (10 total) exposed to that dose of oxacillin. Although cervical disc space infections are rare, they are serious.(ABSTRACT TRUNCATED AT 250 WORDS)

Identification and characterization of human beta 2-chimaerin: association with malignant transformation in astrocytoma.

Molecular processes resulting in the malignant transformation from low- to high-grade astrocytoma remain poorly understood. Using reverse transcriptase PCR, we identified a gene that is differentially expressed in normal brain and low-grade astrocytoma compared to glioblastoma tissues. This gene is identical to human beta 2-chimaerin, which encodes a 468-amino acid GTPase-activating protein for p21rac. The gene was localized to human chromosome 7p15.3 by fluorescence in situ hybridization mapping. Human beta 2-chimaerin is expressed in a variety of human tissues, with the highest expression level detected in human brain and pancreas. RNase protection assays indicated that the expression level of this gene is high in all the normal brain and low-grade astrocytoma samples tested compared to malignant gliomas. The down-regulation of beta 2-chimaerin expression in the high-grade gliomas suggests that decreased expression of this gene may be a feature of progression in the development of malignant glioma.

Childhood ganglioglioma and medically intractable epilepsy. A clinicopathological study of 15 patients and a review of the literature.

Gangliogliomas are an increasingly recognized cause of epilepsy in children. Several studies have shown that early surgical treatment is beneficial, but controversy exists regarding the type of surgical treatment required for optimal seizure control and to prevent tumor recurrence. To address this issue, we performed a retrospective review of 15 children operated on at the Cleveland Clinic during a 7-year period with medically intractable epilepsy who were found to harbor a ganglioglioma during the course of their work-up. Nine patients with mostly nondominant hemisphere tumors underwent tumor resection without the use of electrocorticography to guide additional resection of epileptogenic foci, while 6 other patients with dominant hemisphere tumors had subdural electrode grids placed to extraoperatively map zones of ictal onset and eloquent areas. The extent of tumor resection was then correlated to seizure outcome and tumor recurrence. Of the 11 patients who received a gross total resection, 9 are seizure-free while 2 have a greater than 90% reduction in their seizure frequency (100% 'good' outcome). There was no tumor recurrence in this group. Of the 4 patients who underwent a subtotal tumor resection, 1 is seizure-free while 3 have persistent seizures (25% 'good' outcome). All patients in this group have stable disease on follow-up magnetic resonance imaging. In those patients who received subdural electrode grids, the extent of resection of the zones of ictal onset did not correlate with seizure outcome. The mean follow-up was 42 months. We conclude that complete tumor resection is the most important factor for optimal seizure control and to prevent tumor recurrence.

Gardner's hydrodynamic theory of syringomyelia revisited.

Several theories have been put forth to explain the pathogenesis of syringomyelia, the formation of longitudinal, fluid-filled cavities within the spinal cord. Chief among them is Gardner's hydrodynamic theory, widely accepted for more than two decades. Gardner attributed the genesis of syringomyelia to craniospinal pressure differentials in the setting of fourth ventricular outlet obstruction; these differentials favor cerebrospinal fluid shifts from the fourth ventricle of the brain through the central canal of the spinal cord. Gardner's theory has been questioned, and several alternative theories of syringomyelia have been proposed. Physiological data and new information from magnetic resonance imaging support many of Gardner's concepts; however, a more comprehensive elucidation of the pathophysiologic mechanisms of syringomyelia requires incorporating facets of the other theories. We propose a unified theory of the pathogenesis of syringomyelia based on recent experience with magnetic resonance imaging, and on elements of other current theories.

Optimizing polarization from a XeCl laser.

Conditions in which modest intracavity anisotropic losses generate highly polarized pulsed XeCI laser output are clarified. These conditions are generally applicable to other pulsed lasers.

Symptomatic Chiari malformation in adults: a new classification based on magnetic resonance imaging with clinical and prognostic significance.

Thirty-five consecutive adults with Chiari malformation and progressive symptoms underwent surgical treatment at a single institution over a 3-year period. All patients underwent magnetic resonance imaging scan before and after surgery. Images of the craniovertebral junction confirmed tonsillar herniation in all cases and allowed the definition of two anatomically distinct categories of the Chiari malformation in this age group. Twenty of the 35 patients had concomitant syringomyelia and were classified as Type A. The remaining 15 patients had evidence of frank herniation of the brain stem below the foramen magnum without evidence of syringomyelia and were labeled Type B. Type A patients had a predominant central cord symptomatology; Type B patients exhibited signs and symptoms of brain stem or cerebellar compression. The principal surgical procedure consisted of decompression of the foramen magnum, opening of the fourth ventricular outlet, and plugging of the obex. Significant improvement in preoperative symptoms and signs was observed in 9 of the 20 patients (45%) with syringomyelia (Type A), as compared to 13 of the 15 patients (87%) without syringomyelia (Type B). Postoperative reduction in syrinx volume was observed in 11 of the 20 patients with syringomyelia, including all 9 patients with excellent results. Magnetic resonance imaging has allowed a classification of the adult Chiari malformation in adults based on objective anatomic criteria, with clinical and prognostic relevance. The presence of syringomyelia implies a less favorable response to surgical intervention.

Delayed facial nerve palsy after temporal lobectomy for epilepsy: report of four cases and discussion of possible mechanisms.

Four cases of idiopathic peripheral facial nerve palsy were documented after 110 consecutive resections of the temporal lobe for intractable epilepsy. In 3 of the 4 cases, the palsy was ipsilateral to the side of the temporal lobectomy. The onset of facial weakness was delayed 7 to 13 days after surgery (mean, 9.7 days). One patient underwent facial electroneurography, which documented 17% of normal facial motor function at the height of his weakness and the absence of the acoustic stapedius reflex. All patients were treated with prednisone (60-80 mg per day by mouth for 10-14 days, tapering off throughout the subsequent week). Facial function recovered fully in all patients within 6 to 8 weeks. Possible mechanisms are discussed, including heat and/or mechanical trauma to the facial nerve near the geniculate ganglion during resection of mesial temporal lobe structures.

Intractable epilepsy and structural lesions of the brain: mapping, resection strategies, and seizure outcome.

Forty-seven patients with structural brain lesions on neuroimaging studies and partial epilepsy intractable to medical therapy were studied. Prolonged noninvasive interictal and ictal EEG recording was performed, followed by more focused mapping using chronically implanted subdural electrode plates. Surgical procedures included lesion biopsy, maximal lesion excision, and/or resection of zones of epileptogenesis depending on accessibility and involvement of speech or other functional areas. The epileptogenic zone involved exclusively the region adjacent to the structural lesion in 11 patients. It extended beyond the lesion in 18 patients. Eighteen other patients had remote noncontiguous zones of epileptogenesis. Postoperative control of epilepsy was accomplished in 17 of 18 patients (94%) with complete lesion excision regardless of extent of seizure focus excision. Postoperative control of epilepsy was accomplished in 5 of 6 patients (83%) with incomplete lesion excision but complete seizure focus excision and in 12 of 23 patients (52%) with incomplete lesion excision and incomplete focus excision. The extent of lesion resection was strongly associated with surgical outcome either in itself (p less than 0.003), or in combination with focus excision. Focus resection was marginally associated with surgical outcome as a dichotomous variable (p = 0.048) and showed a trend toward significance (p = 0.07) only as a three-level outcome variable. We conclude that structural lesions are associated with zones of epileptogenesis in neighboring and remote areas of the brain. Maximum resection of the lesion offers the best chance at controlling intractable epilepsy; however, seizure control is achieved in many patients by carefully planned subtotal resection of lesions or foci.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical management of syringomyelia: a five year experience in the era of magnetic resonance imaging.

We summarize our experience with 59 consecutive surgically managed cases of syringomyelia (SM) over a 5 year period. All cases had magnetic resonance imaging (MRI) preoperatively and postoperatively. Twenty-eight patients presented with SM and the adult Chiari (Chiari I) malformation (SM-ACM), 6 patients had post traumatic syrinxes, 14 patients had syrinxes associated with an intramedullary neoplasm, 3 patients had syringomyelia associated with spinal arachnoiditis and 8 patients had idiopathic syringomyelia. Holocord syrinxes were more often associated with SM-ACM, while focal syrinxes were associated with posttraumatic, spinal arachnoiditis and neoplastic conditions. In all cases with neoplasms the MRI revealed parenchymal intramedullary signal abnormalities in addition to the syrinx cavity. Posterior fossa decompression with obex plugging (the Gardner operation) was the procedure of choice for SM-ACM and for idiopathic holocord syringomyelia. Exploration and drainage of the syrinx with or without shunting was carried out mainly for focal syrinxes associated with trauma and neoplasm. Patients with SM-ACM responded well to posterior fossa decompression with satisfactory results in 24/28 patients. Idiopathic SM is probably a forme fruste of SM-ACM and when treated with the Gardner procedure showed good results in all 8 patients. Posttraumatic and neoplastic SM had the least predictable results with surgery. The disappearance of the syrinx on postoperative MRI correlated well with a good surgical outcome.

Extent of resection in temporal lobectomy for epilepsy. I. Interobserver analysis and correlation with seizure outcome.

The extent of resection was assessed in 45 temporal lobectomies for medically intractable epilepsy with mapped temporal lobe foci. Postoperative magnetic resonance imaging (MRI) in the coronal plane was used to quantify the extent of resection of superior lateral, inferior lateral, basal, and medial structures, including the amygdalohippocampal complex. A new 20-compartment model of the temporal lobe was used for this assessment. Blinded interobserver variability was minimal. Intraoperative measurements and maps routinely overestimated the actual extent of resection, especially of medial structures. One year after surgery, 70% of patients remained seizure-free (except for auras). Seizure-free outcome was accomplished despite varying degrees of resection, but was more likely achieved with more extensive resections in all compartments. Among patients with mesiobasal foci, seizure-free outcome correlated significantly with extent of resection of amygdalohippocampal complex. We conclude that assessment of extent of resection by postoperative MRI provides an objective basis of evaluating outcome after temporal lobectomy. It allows a rational approach to understanding of operative failures and is potentially useful in comparing efficacy of various surgical approaches.

Correlation between magnetic resonance imaging and surgical findings in the tethered spinal cord.

Between October 1982 and August 1987, 20 patients underwent magnetic resonance imaging (MRI) and subsequent surgical release of a tethered spinal cord. The tethering was caused by a thick filum terminale in 6 patients. On MRI scans, the conus medullaris was at L4 in 2 patients, at L2 in 3 patients, and the filum terminale appeared thick in 1 patient. The spinal cord was tethered to an intradural lipoma correctly demonstrated by MRI in 6 patients. Increased epidural fat was misdiagnosed as an intradural lipoma in one patient and a lipomatous stalk was not identified in 2 other patients. Scar tissue resulting from repair of a meningocele had tethered the cord in the remaining 8 patients. On MRI scans, the conus medullaris was located between L3 and S3; in 5 of the patients, scar tissue was apparent on the MRI scan. This correlative study supports the use of MRI as the initial, and possibly the only, imaging modality when a tethered spinal cord is suspected. Improved or more recent MRI techniques will help demonstrate these anomalies better.

Intracranial meningiomas in the aged: surgical outcome in the era of computed tomography.

Seventy-five patients older than 60 years of age underwent surgical resection of intracranial meningiomas during a 10-year period at a single institution. All patients had a computed tomographic scan preoperatively, and all were followed for at least 3 months postoperatively. There were 50 patients 61 to 70 years of age (Group A), and 25 patients older than 70 years (Group B). Sixteen patients (21%) were asymptomatic, and no patient was severely disabled preoperatively. Operative morbidity and mortality and outcome at 3 months were assessed and correlated with age, preoperative neurological status, and tumor size and location. Operative mortality was 6.6% (6% in Group A; 8% in Group B). Perioperative morbidity (including medical and surgical complications and worsening in neurological status) was 48% (46% in Group A; 52% in Group B). Neurological status 3 months after surgery was improved by at least one grade as compared to before surgery in 40% of patients (38% in Group A; 44% in Group B), unchanged in 29% (34% in Group A; 20% in Group B), and worsened in 31% (28% in Group A; 36% in Group B). While nearly half of the patients were asymptomatic 3 months after surgery, 11 patients (15%) had died or remained seriously disabled. Outcome at 3 months correlated significantly with low neurological grade preoperatively and with a tumor location over the cortical convexity. There was no significant correlation with age or tumor size. We conclude that resection of intracranial meningiomas is associated with significant morbidity and mortality in the elderly.(ABSTRACT TRUNCATED AT 250 WORDS)