Ophthalmoplegia with bilateral ptosis secondary to midbrain hemorrhage. A case with clinical and radiologic correlation.

A 65-year-old white female presented with the sudden onset of headaches, bilateral ptosis, and complete ophthalmoplegia. Other than a mild decrease in mental status, she was neurologically intact. Magnetic resonance imaging (MRI) and computed tomography (CT) examinations showed a midline hemorrhage extending from the caudal diencephalon to the pontomesencephalic junction affecting the oculomotor complex, the medial longitudinal fasciculus (MLF), and the rostral parapontine reticular formation (PPRF). Ischemic changes were also noted in the midline pontine tegmentum possibly affecting root fibers from the abducens nuclei. Angiography was negative for a vascular anomaly. The radiologic findings are correlated with current models of oculomotor organization to provide an explanation for this patient's unique clinical presentation.

Craniocerebral epidermoid and dermoid tumours: a review of 32 cases.

We reviewed 22 epidermoid and 10 dermoid tumours of the skull and brain from patients operated on consecutively at Henry Ford Hospital between 1975 and 1991. There were 19 intradural (16 epidermoid, 3 dermoid) and 13 extradural (6 epidermoid, 7 dermoid) lesions. The average age at presentation was 35 years for patients with epidermoids and 15 years for those with dermoids. Common clinical presentations for patients with intradural lesions included headache, visual deficits, and seizures, whereas patients with extradural lesions harbored asymptomatic scalp masses. All patients with intradural lesions were investigated with computed tomography (CT) and cerebral angiography, and 8 patients underwent magnetic resonance imaging (MRI). Total resection was possible in 12 (92%) of 13 extradural tumours, all with excellent outcomes. Eight (42%) of the intradural tumours were completely resected. Overall, with the intradural tumours we had good to excellent results in 17 patients (90%), poor results in 1 (5%), and 1 death (5%). Re-operation was needed in 5 intradural recurrences (26%) with deterioration in only one patient's neurologic status postoperatively. From a review of ours and others' data, we conclude that 1) these tumours have an insidious onset despite significant size and mass effect as demonstrated by imaging studies; 2) CT, angiography, and particularly MRI help to define the extent of subarachnoid tumour spread and involvement of neurovascular structures, thus permitting better surgical planning; 3) a significant number of intradural tumours are difficult to excise because of their adherence to neurovascular structures, and thus are related to higher morbidity and mortality; and 4) because of extremely slow growth, complete tumour resection should not be the goal at the risk of injury to neurovascular structures.

Atypical and malignant meningiomas: a clinicopathological review.

There has been continuing debate on the subject of malignant meningiomas, but few studies of large series have been reported. We present our experiences with 25 atypical and malignant meningiomas operated on at Henry Ford Hospital between 1976 and 1990. A total of 319 primary intracranial meningiomas were operated on during this period; of these, 294 (92%) were benign, 20 (6.26%) atypical, and 5 (1.7%) malignant. We used a modified histological grading system, based primarily on World Health Organization criteria of malignancy (hypercellularity, loss of architecture, nuclear pleomorphism, mitotic index, tumor necrosis, and brain invasion), to define atypical and malignant meningiomas. Each of these criteria was given a score from 0 to 3, and then partial scores were added to obtain cumulative scores. These total scores were then used to determine what is benign, atypical, and malignant. The peak incidence of atypical and malignant meningiomas was in the seventh and sixth decades, respectively. The predominance of female patients with benign meningiomas was not observed in the nonbenign group. The male:female ratio for atypical and malignant meningiomas was 1:0.9 versus 1:2.3 for benign meningiomas (P = 0.024). The most common presenting symptom and physical sign in our patients was paresis. In reviewing their radiographic features, all patients showed moderate or marked edema on computed tomography. Calcification was exhibited by one patient only and "mushrooming" was seen in three cases. Of the 25 patients, 11 (44%) died during follow-up: 2 in the perioperative period, 8 within the first 5 years, and 1 died 11 years after the diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Hypothermic circulatory arrest and the management of giant and large cerebral aneurysms.

The surgical adjuncts of hypothermic circulatory arrest, exsanguination, and barbiturate cerebral protection were evaluated in nine cases of cerebral aneurysms felt unapproachable by conventional surgery. These techniques were used in seven posterior circulation aneurysms, two of which were giant and two giant anterior circulation aneurysms originating at the middle cerebral artery bifurcation. Four patients had excellent outcomes, two had a fair result, one had a poor result, and two died. The outcome of surgery reflected that of the management of patients with unruptured or ruptured aneurysms. Three of the four patients who did well had unruptured aneurysms, and all three of the cases in which death or a poor outcome resulted occurred in patients presenting with subarachnoid hemorrhage. The rationale for the use of hypothermic circulatory arrest is discussed, and the surgical indications, techniques, and anesthetic considerations are also reviewed.

Transoral surgery: an anatomic study.

The transoral approaches have become commonplace in modern neurosurgical practice for treatment of ventral midline lesions of the clivus and upper cervical spine. Although the standard technique of transoral surgery is conceptually simple, anatomic relationships are not so readily appreciated. The present study was undertaken in an effort to define more clearly the midline anatomic relationships as they pertain to the standard transoral and transpalatine operations. The anatomic relationships involved in planning microsurgical transoral approaches were examined in 15 human cadavers. Landmarks approximating the midline of the skull base and the upper cervical spinal canal were defined to assist the surgeon's orientation. Measurements were made in axial, sagital, and parasagittal planes to various neurovascular structures in the posterior cranial fossa and upper cervical spinal canal. The study revealed that, for the standard transoral and transoral-transpalatine dissections, the carotid arteries, abducens nerves, interior petrosal sinuses, hypoglossal nerves, and vertebral arteries would be a greatest risk being 0.76, 1.06, 1.51, 1.34, and 1.52 cm from the midline at specified locations. The measurements and the computed tomography images provide a useful reference for the surgeon.

Disabling cerebral transient ischemic attacks.

The surgical management of an emerging clinical entity, namely disabling transient cerebral ischemic attacks, is described. A series of 19 patients treated in a 2-year period (12 with anterior circulation dysfunction and seven with posterior insufficiency) met the following criteria: 1) stereotypical recurrent episodes of transient neurological dysfunction related to the anterior or posterior circulation distribution; 2) failure of maximum medical therapy to control the transient neurological dysfunction; 3) four-vessel cerebral angiography demonstrating an isolated vascular territory corresponding to patient symptoms; 4) inhalation xenon cerebral blood flow studies with at least three of eight probe-pairs showing significant asymmetries in the initial slope index, localizing an area of relative oligemia to the symptomatic hemisphere (anterior circulation only); and 5) severe restriction of lifestyle due to transient ischemic attacks (TIA's). Seventeen patients underwent surgical bypass therapy: deep sylvian superficial temporal artery (STA)-middle cerebral artery (MCA) bypass in nine; surface STA-MCA bypass in three; STA-superior cerebellar artery bypass in three; STA-posterior cerebral artery bypass in one; and aorta-carotid artery bypass in one. There was one perioperative death and four perioperative strokes (two ipsilateral and two contralateral to the operated side). The average follow-up period was 14 months. Of the 16 surviving surgically treated patients, 13 (81%) have had an excellent to good outcome with complete resolution of TIA's and minimal neurological deficits. Three patients had a poor outcome with either a significant persistent neurological deficit or continued TIA's. The two patients not treated surgically continue to have vertebrobasilar insufficiency episodes while receiving oral anticoagulation medication. The overall mortality rate (5.5%) and stroke morbidity rate (22.2%) of surgical therapy for disabling TIA's are high in this neurologically unstable group of patients, but are associated with an 81% excellent to good response. Although the natural history of disabling TIA's is not known, these patients present with significant to total disability due to their symptoms. It is concluded that disabling TIA's respond to surgical revascularization and may represent an indication for cerebral revascularization surgery.

Surgical removal of metastatic renal adenocarcinoma to the midbrain tectum: a case report.

A patient with adenocarcinoma of the kidney metastatic to the quadrigeminal plate of the midbrain presented with acute obstructive hydrocephalus and early tonsillar herniation. Because the majority of these carcinomas are resistant to radiation therapy, only limited treatment choices were available. Initially, a ventriculoperitoneal shunt relieved the hydrocephalus and neurologic symptoms. After a short course of improvement, with decompressed ventricles demonstrated by postoperative computed tomography, the patient developed additional neurologic signs, leading to the decision to excise the metastatic tumor. Convalescence was complicated but the patient survived for six months, succumbing to respiratory failure presumably caused by lung metastases.