Should asymptomatic cervical stenosis be treated in the setting of progressive thoracic myelopathy? A systematic review of the literature.

PURPOSE: Unlike tandem stenosis of the cervical and lumbar spine, tandem cervical and thoracic stenosis (TCTS) of the spine is less common, and the approach and order of intervention are controversial. We aim to review the literature to evaluate the incidence and interventions for patients with cervical and thoracic stenosis. We provide illustrative cases to demonstrate that thoracic myelopathy in the setting of asymptomatic cervical stenosis can be treated safely. METHODS: A systematic review of the literature through electronic databases of PubMed, EMBASE, Web of Science, and Cochrane Library was performed to present the current literature that evaluates TCTS as it relates to incidence and surgical interventions. We also present two cases of patients undergoing operative intervention for thoracic myelopathy in the setting of concurrent cervical stenosis. RESULTS: A total of 26 English original studies and case reports were identified. Nine studies evaluated the incidence of TCTS. 20 studies with a total of 168 patients with TCTS presented information on surgical intervention options. There is an overall aggregate incidence of 11.6% (530/4751) based on incidence studies. 165 patients underwent thoracic intervention. Of these patients, 63 patients underwent cervical intervention first, 29 underwent thoracic intervention first, and 73 underwent simultaneous, single-stage intervention. CONCLUSIONS: In patients presenting with myelopathy, both cervical and thoracic spine should be evaluated for TCTS. Order of operative intervention is tailored to clinical and radiographic information. In cases of thoracic myelopathy with asymptomatic cervical stenosis, thoracic intervention can be pursued with precautions to prevent further cervical cord injury.

Subtotal calvarial vault reconstruction utilizing a customized polyetheretherketone (PEEK) implant with chimeric microvascular soft tissue coverage in a patient with syndrome of the trephined: A case report.

The syndrome of the trephined is a neurologic phenomenon that manifests as sudden decline in cognition, behavior, and sensorimotor function due to loss of intracranial domain. This scenario typically occurs in the setting of large craniectomy defects, resulting from trauma, infection, and/or oncologic extirpation. Cranioplasty has been shown to reverse these symptoms by normalizing cerebral hemodynamics and metabolism. However, successful reconstruction may be difficult in patients with complex and/or hostile calvarial defects. We present the case of a 48-year-old male with a large cranial bone defect, who failed autologous cranioplasty secondary to infection, and developed rapid neurologic deterioration leading to a near-vegetative state. Following debridement and antibiotic therapy, delayed cranioplasty was accomplished using a polyetheretherketone (PEEK) implant with free chimeric latissimus dorsi/serratus anterior myocutaneous flap transfer for vascularized resurfacing. Significant improvements in cognition and motor skill were noted in the early postoperative period. At 6-month follow-up, the patient had regained the ability to speak, ambulate and self-feed-correlating with evidence of cerebral/ventricular re-expansion on computed tomography. Based on our findings, we advocate delayed alloplastic implantation with total vascularized soft tissue coverage as a viable alternative for reconstructing extensive, hostile calvarial defects in patients with the syndrome of the trephined.

Creating a Culture of Collaboration: A Brief History of Academic Neurosurgery in Washington, DC.

Clinical neurosurgery has been practiced in the US capital for just over 100 years. As former residents and fellows of Drs. Harvey Cushing and Walter Dandy moved to the region, hospitals at Georgetown and George Washington Universities became early adopters of this new surgical discipline. Later academic neurosurgery programs were established at the National Institutes of Health, Walter Reed Medical Center, and Children's National Medical Center. Neurosurgical pioneers at these institutions developed new technologies and diagnostic procedures which continue to inform our current practice. In addition, continued collaboration between the multiple training sites in Washington, DC has uniquely enriched our residents' training experience.

Real-Time Evaluation of Anterior Choroidal Artery Patency During Aneurysm Clipping.

Inadvertent occlusion of the anterior choroidal artery during aneurysm clipping can cause a disabling stroke in minutes. We evaluate the clinical utility of direct cortical motor evoked potential (MEP) monitoring during aneurysm clipping, as a real-time assessment of arterial patency, prior to performing indocyanine green videoangiography.   Direct cortical MEPs were recorded in seven patients undergoing surgery for aneurysms that involved or abutted the anterior choroidal artery. The aneurysms clipped in those seven patients included four anterior choroidal artery aneurysms and six posterior communicating artery aneurysms. Serial MEP recordings were performed during the intradural dissection, aneurysm exposure, and clip placement. A significant change in MEPs after clip placement would prompt immediate inspection and removal or repositioning of the clip. If the clip placement appeared satisfactory and MEP recordings were stable, then an intraoperative indocyanine green videoangiogram was performed to confirm obliteration of the aneurysm and patency of the arteries.  Seven patients underwent successful clipping of anterior choroidal artery aneurysms and posterior communicating artery aneurysms using direct cortical MEP monitoring, with good clinical and radiographic outcomes. In six patients, no changes in MEP amplitudes were observed following permanent clip placement. In one patient, a profound decrease in MEP amplitude occurred 220 seconds after placement of a permanent clip on a large posterior communicating aneurysm. An inspection revealed that the anterior choroidal artery was kinked. The clip was immediately removed, and the MEP signals returned to baseline shortly thereafter. A clip was then optimally placed, and the patient awoke without neurologic deficit.  Direct cortical MEPs are a useful adjunct to standard electrophysiologic monitoring in aneurysm surgery, particularly when the anterior choroidal artery or lenticulostriate arteries are at risk. When these arteries are occluded, infarction may occur before the occlusion is detected by indocyanine green videoangiography or intraoperative angiography. The use of MEPs allows real-time detection of ischemia to subcortical motor pathways.

Laparoscopic-assisted Peritoneal Shunt Insertion for Ventriculoperitoneal and Lumboperitoneal Shunt Placement: An Institutional Experience of 53 Consecutive Cases.

PURPOSE: The purpose of this study was to describe operative times, complication rates, and outcomes following laparoscopic placement of the peritoneal catheter in ventriculoperitoneal (VP) and lumboperitoneal (LP) shunt insertion. METHODS: A retrospective review was performed of those who underwent laparoscopic-assisted VP or LP shunt insertion from July 2007 to August 2011. RESULTS: The study included 53 consecutive patients (35 women and 18 men). Mean age was 51 years (range, 16 to 83 y), mean BMI was 27.6 (range, 16 to 54), and 35.8% of the patients had previous abdominal surgery. Mean operative time for VP shunt placement was 68.2 ± 19.0 minutes, and for LP shunt placement 84 ± 12.4 minutes. There were no intraoperative complications, and conversion to minilaparotomy was 0%. There were 2 distal catheter-associated complications. CONCLUSIONS: Laparoscopic-assisted VP/LP shunt placement is associated with a low incidence of distal catheter malfunction. Direct visualization of shunt placement into the peritoneal cavity is a major advantage making it a viable alternative over traditional techniques.

Surgical management of a paraclinoid aneurysm containing a displaced neuroform microstent: technical case report.

OBJECTIVE: We report the first case of clip obliteration of a cerebral aneurysm containing a displaced microstent. CLINICAL PRESENTATION: A 63-year-old woman presented with a 6-month history of headaches. She had no other neurological symptoms, and her examination was normal. A computed tomographic scan showed no evidence of hemorrhage. Angiography confirmed the presence of a large left paraclinoid aneurysm. INTERVENTION: The patient initially underwent attempted endovascular repair of the aneurysm. A Neuroform microstent (Boston Scientific, Natick, MA), which was placed across the aneurysm neck, migrated into the aneurysm upon passing through it with the microcatheter to be used to place coils. This left the proximal half of the stent in the aneurysm and the distal half in the internal carotid artery. Attempts to remove the stent and to place a second stent across the neck of the aneurysm failed, and any plans to place coils were aborted. Three months after the failed endovascular procedure, the patient consented to a craniotomy. The aneurysm was successfully obliterated by placing several clips directly across the neck of the aneurysm and leaving the stent in place. CONCLUSION: The patient experienced an excellent clinical and angiographic outcome. Although not the ideal treatment strategy, this report illustrates that clip obliteration of aneurysms containing displaced microstents can be performed successfully for this complication of endovascular treatment.

Atypical teratoid rhabdoid tumor (AT/RT) in adults: review of four cases.

Atypical teratoid/rhabdoid (AT/RT) tumor is a rare, highly malignant tumor of the central nervous system (CNS) most commonly found in children less than 5 years of age. Although the vast majority of cases are diagnosed in young children, there have been isolated case reports in adults. Since its histological appearance can be confused with other tumors, especially in adults, separating AT/RT from other neoplasms may be difficult. In many instances, a reliable diagnosis is not possible without demonstrating the lack of nuclear INI1 protein expression by immunohistochemical methods. The patients (three males and one female) ranged in age from 23 to 42 years (mean age, 32 years). Radiographically, two tumors were localized in the right fronto-parietal region, one was frontal and the other was found in the left temporal lobe. Varying degrees of hydrocephalus and heterogeneous enhancement were present on MRI. In all cases, diagnosis during intraoperative consultation and preliminary diagnosis was different from the final diagnosis after immunohistochemical analysis. Immunohistochemical staining showed that the tumor cells were positive for vimentin and reacted variably for keratin, epithelial membrane antigen (EMA), synaptophysin, neurofilament protein, CD34, and smooth muscle actin (SMA). All were negative for GFAP, S-100, desmin and CD99. Three of the four cases lacked nuclear expression of INI1. One patient is alive with no evidence of disease 17 years after the diagnosis. In adult examples of AT/RT, the diagnosis requires a high index of suspicion, with early tissue diagnosis and a low threshold for investigation with INI1 immunohistochemistry to differentiate this entity from other morphologically similar tumors. Although the prognosis is dismal in pediatric population, long term survival is possible in adult AT/RT cases after surgery and adjuvant radiotherapy and chemotherapy.

Spontaneous resolution of syringomyelia and Chiari malformation Type I in a patient with cerebrospinal fluid otorrhea. Case report.

The spontaneous resolution of syringomyelia in the setting of a Chiari malformation Type I (CM-I) has been reported infrequently. Several theories about the pathogenesis and spontaneous resolution of syringomyelia associated with CM-I have been proposed. The authors present the case of a patient with spontaneous resolution of a CM-I and syringomyelia coinciding with the development of cerebrospinal fluid (CSF) otorrhea. Although cases of spontaneous resolution of syringomyelia have been reported, this is the first reported case of spontaneous resolution of syringomyelia and a CM-I associated with the simultaneous development of CSF otorrhea.

Complex Expression Patterns for Na+,K+-ATPase Isoforms in Retina and Optic Nerve.

Three genetically distinct isozymes of the catalytic subunit of the Na,K-ATPase have been detected and have been designated alpha1, alpha2, and alpha3. To determine whether their expression is restricted to identifiable neurons and glia, specific monoclonal antibodies were used for immunofluorescent localization in the rat retina and optic nerve. The patterns of staining were markedly different, suggesting differences in cellular localization. Photoreceptor inner segments and optic nerve fibers expressed predominantly alpha3. Müller glia in the retina and astrocytes in the optic nerve expressed alpha1 and alpha2. Isolated, dissociated bipolar, horizontal, and Müller cells expressed different isozymes separately or in combination. The complexity of staining of neurons and their axons and dendrites suggested that Na,K-ATPase isozyme expression is not stereotyped, but is tailored to the ion transport needs of individual cell types, and targeted to specified membrane domains.