Tuesday, January 31, 2012

Minimally Invasive Posterior Atlantoaxial Fusion: A Cadaveric and Clinical Feasibility Study

Publication year: 2012
Source: World Neurosurgery, Available online 30 January 2012
Alexander Taghva, Frank Attenello, Gabriel Zada, Alexander Khalessi, Patrick C. Hsieh
ObjectiveMinimally invasive surgical(MIS) techniques show several potential advantages over open techniques, including decreased blood loss, post-operative pain, and recovery time. Our study aimed to demonstrate atlantoaxial fusion using MIS techniques, shown previously in only two reports. Smaller operating corridor with MIS may increase difficulty of instrumentation placement and risk of instrumentation-related complications.MethodsFive cadaveric specimens were studied pre-surgically with CT determining bony anatomy, vertebral artery course, and trajectory for C1/C2 screw placement. Four specimens had adequate C2 pedicle sizes to accommodate screw placement. Specimens were used to perform C1-2 instrumentation through minimal access tubular retractors. Following procedures, specimens were re-examined with CT to assess accuracy of MIS C1-2 screw placement.ResultsThrough minimal access expandable tubular retractors, C1-lateral mass and C2 pedicle screws were placed in all four specimens. Post-instrumentation CT analysis demonstrated no violation of the foramen transversarium in all cases. There was one grade 1 medial breach from C1 lateral mass screw placement. Two patients with type-2 odontoid fracture were treated with MIS C1-2 fusion with follow-up 4-24 months. Average operating time was 3.5 hours, and average surgical blood loss was 125 milliliters. Both cases were examined with CT scan post-surgically and there were no bony breaches with screw placement. Both patients remained neurologically intact postoperatively with significant improvement in pain scores. Followup imaging at two years demonstrates union of odontoid fracture.ConclusionsMinimally invasive atlantoaxial fixation is feasible and safe. Preoperative CT is paramount for preoperative evaluation of the vertebral artery anatomy in relation to C1/2 vertebra.





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Monday, January 30, 2012

Infant Brain Yields Autism Clues (CME/CE)

(MedPage Today) -- Infants' brain responses to people looking at or away from them may someday help identify those at risk for developing an autism spectrum disorder (ASD), researchers found.





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Balloon Better Emboli Guard in Carotid Stenting (CME/CE)

(MedPage Today) -- Occluding the proximal carotid artery with a balloon may confer better protection against cerebral embolization than a filter device during carotid stenting, a randomized trial found.





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Brain Bleeds High in Expectant Blacks, Hypertensives (CME/CE)

(MedPage Today) -- African-American women and women who develop hypertension are at risk for subarachnoid hemorrhage associated with pregnancy, a retrospective study found.





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Saturday, January 28, 2012

A single-centre experience and follow-up of patients with endovascular coiling of large and giant in

Publication year: 2012
Source: Journal of Clinical Neuroscience, Available online 24 January 2012
Xu Gao, Guobiao Liang, Zhiqing Li, Xuezhong Wei, Peng Cao
Large and giant aneurysms are some of the most challenging vascular pathologies in the central nervous system. Their peculiarities make the surgical and endovascular approaches difficult and frequently limit them by posing risks and complications. Endovascular coil embolization of these lesions is being used increasingly as an alternative. Here we report the clinical experience and follow-up results of the endosaccular packing of 102 consecutive patients with 106 large or giant aneurysms to assess the efficacy and safety of this method. Embolization was completed by packing the aneurysm sac with a variety of commercially available coils. Primary endosaccular coiling, balloon-assisted coiling and stent-assisted coiling were used. The technical feasibility of the procedure, procedure-related complications, angiographic results, clinical outcome and follow-up angiography were evaluated. During admission, immediate angiography demonstrated complete occlusion in 48.1%, neck remnant in 28.3%, and incomplete occlusion in 23.6%. Procedure-related morbidity and mortality was 7.5% and 2.8%, respectively. A favorable clinical outcome (Modified Rankin Scale score of 0–2) was observed in 88.2% of patients (average follow-up time, 56.5 months). No re-hemorrhage of a treated aneurysm occurred. Angiography follow-up was obtained in 77.5% (79/102) patients (average follow-up time, 38.1 months). The overall recanalization rate was 29.6%. Comparison of occlusion class immediately after treatment and at last follow-up showed that 80.2% of the 81 aneurysms (in 79 patients) were stable or had improved. Five stent-assisted aneurysms that were not completely occluded initially had converted to complete occlusion on last follow-up. Nineteen recanalized aneurysms underwent successful re-embolization. No procedural complication was seen at retreatment. We conclude that in treating large and giant intracranial aneurysms, endovascular coiling with parent vessel preservation is a safe and effective technique.





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Disappearance of aneurysms associated with moyamoya disease after STA–MCA anastomosis with encephalo

Publication year: 2012
Source: Journal of Clinical Neuroscience, Available online 25 January 2012
Wei Ni, Feng Xu, Bin Xu, Yujun Liao, Yuxiang Gu, ...
Moyamoya disease is a rare cerebrovascular disease characterized by steno-occlusive vasculopathy affecting the terminal internal carotid arteries. Although the effect of direct arterial bypass on the prevention of recurrent haemorrhage or ischemic events in patients with hemorrhagic moyamoya disease has been demonstrated, disappearance of aneurysms associated with moyamoya disease has rarely been reported. In this study, we present two patients with aneurysms associated with moyamoya disease. After superficial temporal artery to middle cerebral artery anastomosis combined with encephaloduro myosynangiosis, the aneurysms on the moyamoya vessels disappeared, which was confirmed by follow-up angiography.





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The role of transcranial Doppler ultrasound monitoring in patients with aneurysmal subarachnoid haem

Publication year: 2012
Source: Journal of Clinical Neuroscience, Available online 25 January 2012
Smita Deb, Andrew J. Gogos, Katharine J. Drummond, Peter J. Teddy
The effect of transcranial Doppler (TCD) ultrasound monitoring of vasospasm on patient management following aneurysmal subarachnoid haemorrhage (aSAH) remains unclear. We reviewed our departmental use of TCD by retrospectively analysing 152 medical records. Results of investigations and management changes, including frequency of neurological monitoring and changes in triple H therapy, were examined. TCD monitoring occurred in 87 patients (57%) by untrained neurosurgical registrars. There was high variability in the number of operators for each patient (over 50% of patients had more than two different operators), insonation protocol and monitoring duration (at least 50% of patients were monitored for fewer than seven days). TCD results influenced management in only 18 (12%) patients, while clinical deterioration or improvement dictated more than 80% of changes in triple H therapy and neurological monitoring. Prospective validation in similar neurosurgical settings is needed to justify continued usage of TCD monitoring. Formal training for operators and a standard monitoring protocol should also be considered to increase TCD utility. Prospective evaluation of TCD at our centre has recently been completed.





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Surgical Treatment and Long-term Outcomes of Thalamic Cavernous Malformations

Publication year: 2012
Source: World Neurosurgery, Available online 26 January 2012
Da Li, Junting Zhang, Shuyu Hao, Jie Tang, Xinru Xiao, ...
ObjectiveResection of thalamic cavernous malformations (CMs) is controversial. The goals of this study were to evaluate the outcome of thalamic CMs after surgical resection, assess predictors of prognosis and review the literature.MethodsThe authors used the modified Rankin Scale (mRS) to retrospectively evaluate the presentation, surgery and outcomes of 27 consecutive patients who underwent thalamic CMs micro-resection using six different approaches between 1998 and 2010.ResultsForty-eight hemorrhages occurred in 27 patients (13 male, 14 female with a mean age 33.9 years) with a preoperative mRS score of 2.6±1.0 and a preoperative bleeding rate per patient year of 5.2%. Complete resection was achieved in 26 patients (96.3%) without surgical mortality. The postoperative mRS score at discharge was 1.9±1.0. One lesion rebled one month after complete surgical resection. After a mean follow-up duration of 48.7±43.2mo, the mean mRS score was 1.2±1.2, the postoperative rebleeding rate was 0.91% per patient year. With regard to neurological function, 81.5% of patients improved, 11.1% stabilized and 7.4% worsened. Good outcomes (mRS score≤2, living independently) were achieved in 21 patients (77.8%). Long-term surgical morbidity was observed in 5 patients (18.2%). A multivariate logistic regression analysis identified age (<40) as the only predictor of the postoperative mRS score (≤2) (odds ratio, 1.24, 95% confidence interval, 1.02-1.52;P= 0.035).ConclusionTo the best of our knowledge, this is the largest case series reported in the literature to date. Patients with thalamic CMs can obtain a favorable prognosis using microsurgery; an appropriate microsurgical approach contributes to an excellent outcome.





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The Long-term Outcome Predictors of Pure Microvascular Decompression for Primary Trigeminal Neuralgi

Publication year: 2012
Source: World Neurosurgery, Available online 26 January 2012
Heng Zhang, Ding Lei, Chao You, Bo-Yong Mao, Bo Wu, ...
ObjectiveThe aim of this study is to provide credible and comparable evidence on the efficacy and safety of pure MVD for primary TN, and also to find out the possible prognostic factors of excellent long-term outcome after the surgery.MethodA prospective cohort study was conducted, involving the patients who met the diagnostic criteria of primary TN (both typical and atypical). The cohort patients underwent pure MVD, and then were followed up by independent neurologists. The possible prognostic factors were analyzed via Logistic method.ResultAll 154 consecutive primary TN patients (98 typical cases, 56 atypical cases) underwent pure MVD from January 2001 to November 2005. The patients were followed up for median 5.6 years (10 lost in 5 years). Respective initial and 5-year's complete pain-free without medication (BNI pain scored I) rates were 84% and 72% for total primary TN, 87% and 80% for typical TN, while 79% and 54% for atypical TN. The Kaplan-Meier survival curves of 5 years demonstrated different long-term outcomes in different groups (typical TN vs. atypical TN). The typical symptoms (OR 2.776), preoperative MR indicating vessel compression (OR 2.950), and obvious vessel compression found during operation (OR 3.219) were proved having positive effect on long-term pain relief without medication.ConclusionThis is a perspective cohort study of pure MVD, which confirms the long-term effectiveness and safety of the surgery for primary TN. Patients with typical symptoms, positive MR findings, or obvious vessel compressions might have better long-term prognosis.





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Factors influencing 2-year health care costs in patients undergoing revision lumbar fusion procedure

Journal of Neurosurgery: Spine, Volume 0, Issue 0, Page 1-6, Ahead of Print.
Object Revision lumbar fusion procedures are technically challenging and can be associated with tremendous health care resource utilization and cost. There is a paucity of data regarding specific factors that significantly contribute to increased cost of care. In light of this, the authors set out to identify independent risk factors predictive of increasing 2-year direct health care costs after revision lumbar fusion. Methods One hundred fifty patients undergoing revision instrument-assisted fusion for adjacent-segment disease (50 cases), pseudarthrosis (47 cases), or same-level stenosis (53 cases) were included in this study. Patient demographics, comorbidities, preoperative health states as assessed by patient-reported outcome questionnaires and perioperative complications were collected and analyzed. Two-year back-related medical resource utilization and direct health care costs were assessed. The independent association of all variables to increasing cost was assessed using multivariate linear regression analysis. Results There was a wide range ($24,935–$63,769) in overall 2-year direct costs for patients undergoing revision lumbar fusion (mean $32,915 ± $8344 [± SD]). Preoperative variables independently associated with 2-year direct health care costs included diagnosis of congestive heart failure, more severe leg pain (visual analog scale), greater back-related disability (Oswestry Disability Index), and worse mental health (12-Item Short Form Health Survey Mental Component Summary score). There was a 1.1- to 1.2-fold increase in cost for patients in the greatest quartiles compared with those in the lowest quartiles for these variables. Surgical site infection, return to the operating room, and spine-related hospital readmission during the 90-day global health period were postoperative variables independently associated with 2-year cost. Patients in the greatest versus lowest quartiles had a 1.7- to 1.9-fold increase in cost for these variables. Conclusions Revision lumbar fusion can be associated with considerable 2-year health care costs. These costs can also vary widely among patients, as evidenced by the 2.6-fold overall cost range in this series. Although comorbidities and preoperative severity of disease states contribute to cost of care, the primary drivers of increased cost include perioperative complications such as surgical site infection, return to the operating room, and readmission during the global health period. Measures focused on health service improvement will be most successful in reducing the cost of care for patients undergoing revision lumbar fusion.





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Endonasal management of sellar arachnoid cysts: simple cyst obliteration technique

Journal of Neurosurgery, Volume 0, Issue 0, Page 1-13, Ahead of Print.
Object Symptomatic sellar arachnoid cysts (ACs) have typically been treated via the transsphenoidal route. After sellar cyst wall fenestration, some authors have advocated cyst wall resection and increasing communication between the AC and suprasellar subarachnoid space (SAS). This study is a report of the authors' experience using a simplified approach to reinforce a defective diaphragma sellae or unseen arachnoid diverticulum by deliberately not enlarging the AC-SAS communication and obliterating the cyst cavity with adipose tissue followed by skull base reconstruction. Methods A retrospective analysis was conducted of patients who underwent an endonasal transsphenoidal obliteration of symptomatic ACs with a fat graft and skull base repair. Results Between July 1998 and September 2010, 8 patients with a sellar AC were identified (6 women and 2 men, mean age 57 years). Clinical presentation included headache, pituitary dysfunction, and visual dysfunction (4 patients each group). Maximal cyst diameter averaged 22 mm (range 15–32 mm). In all cases the sellar communication to the SAS was deliberately not enlarged. The endoscope was used for visualization in 8 of 9 procedures. Postoperatively, headache improved in all 4 patients, vision in all 4 patients, and partial resolution of endocrine dysfunction (hyperprolactinemia and/or recurrent hyponatremia) occurred in 3 (75%) of 4 patients. No new endocrinopathy, CSF leak, meningitis, or neurological deficits occurred. Two patients experienced cyst reaccumulation: 1 symptomatic recurrence was treated with reoperation at 43 months postsurgery, and 1 asymptomatic partial recurrence continued to be monitored at 29 months postsurgery. Conclusions Sellar ACs can be effectively treated using endonasal fenestration and obliteration with fat with resultant reversal of presenting symptoms in the majority of patients. This simplified technique of AC cavity obliteration without enlarging communication to the SAS has a low risk of CSF leakage, and in most cases appears to effectively disrupt cyst progression, although longer follow-up is required to monitor for cyst recurrence.





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Friday, January 27, 2012

Stimulating Cognitive Activity Lowers Risk Of Alzheimer's

Findings published Online First by Archives of Neurology, a JAMA/Archives journal, show that people who keep their brain active throughout their lives with cognitively stimulating activities like reading, writing and playing games seem to have lower levels of the β-amyloid protein, which is the major part of the amyloid plaque in Alzheimer disease...





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André Báfica recebe International Early Career Award da Howard Hughes

DO SITE DO HHMI (aqui)

JANUARY 24, 2012 World-Class Scientists Chosen for HHMI's First International Early Career Award







Top biomedical scientists from 12 countries will receive an important boost at a critical time in their careers from HHMI's inaugural International Early Career Scientist (IECS) awards.



The 28 recipients, chosen from 760 applicants, represent a wide range of





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Brain Scans Spot Early Signs of Dyslexia

Scientists now say they can identify dyslexia even before children start school, long before they become labeled as poor students and begin to lose confidence in themselves.
Reuters Health Information





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Thursday, January 26, 2012

Diagnosis and management of the epilepsies in adults and children: summary of updated NICE guidance

Epilepsy is a common neurological disorder characterised by recurring epileptic seizures; it is not a single diagnosis but is a symptom with many underlying causes, more accurately termed the...





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Are Some Science Stories Inevitably Political?

RALEIGH, N.C. Does writing about climate change or childhood vaccinations necessarily mean you've got an agenda? That's one of the questions tackled at last week's ScienceOnline 2012 meeting, a gathering of some 450 scientists, bloggers, scientist-bloggers, journalists and other communicators on the campus of North Carolina State University.

In this particular session, " You Got Your Politics in My Science ," attendees related their experiences and their approaches to dealing with perceived advocacy and reactive attacks. Everyone realizes that both scientists and journalists strive for impartiality. Yet certain hot-button topics invite scrutiny. Heather Goldstone, who reports for a public-radio affiliate and hosts Climatetide.org , mentioned that whenever she wrote about climate change or evolution, she was asked if she's advocating for something, even by her editors.

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Are Some Science Stories Inevitably Political?

RALEIGH, N.C. Does writing about climate change or childhood vaccinations necessarily mean you've got an agenda? That's one of the questions tackled at last week's ScienceOnline 2012 meeting, a gathering of some 450 scientists, bloggers, scientist-bloggers, journalists and other communicators on the campus of North Carolina State University.

In this particular session, " You Got Your Politics in My Science ," attendees related their experiences and their approaches to dealing with perceived advocacy and reactive attacks. Everyone realizes that both scientists and journalists strive for impartiality. Yet certain hot-button topics invite scrutiny. Heather Goldstone, who reports for a public-radio affiliate and hosts Climatetide.org , mentioned that whenever she wrote about climate change or evolution, she was asked if she's advocating for something, even by her editors.

[More]

Add to digg Add to StumbleUpon Add to Reddit Add to Facebook Add to del.icio.us Email this Article





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Antimicrobial Scrubs May Counter MRSA

Healthcare workers wearing antimicrobial-impregnated scrubs had lower burdens of MRSA compared with control participants.
Medscape Medical News





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Dyslexic Kids Show Brain Changes at an Early Age (CME/CE)

(MedPage Today) -- Young children at risk for developing dyslexia showed abnormalities on functional MRI brain scans even before they began learning to read, researchers found.





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Screen All Patients for Abuse, Says Neurology Group (CME/CE)

(MedPage Today) -- Screening patients for abuse should be a priority because of the many neurologic consequences of intimate partner violence, according to a position statement from the American Academy of Neurology.





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A multifaceted program for improving quality of care in intensive care units: IATROREF study*

Objective: To test the effects of three multifaceted safety programs designed to decrease insulin administration errors, anticoagulant prescription and administration errors, and errors leading to accidental removal of endotracheal tubes and central venous catheters, respectively. Medical errors and adverse events are associated with increased mortality in intensive care patients, indicating an urgent need for prevention programs. Design: Multicenter cluster-randomized study. Setting: One medical intensive care unit in a university hospital and two medical–surgical intensive care units in community hospitals belonging to the Outcomerea Study Group. Patients: Consecutive patients >18 yrs admitted from January 2007 to January 2008 to the intensive care units. Interventions: We tested three multifaceted safety programs vs. standard care in random order, each over 2.5 months, after a 1.5-month observation period. Measurements and Main Results: Incidence rates of medical errors/1000 patient-days in the multifaceted safety program and standard-care groups were compared using adjusted hierarchical models. In 2117 patients with 15,014 patient-days, 8520 medical errors (567.5/1000 patient-days) were reported, including 1438 adverse events (16.9%, 95.8/1000 patient-days). The insulin multifaceted safety program significantly decreased errors during implementation (risk ratio 0.65; 95% confidence interval [CI] 0.52–0.82; p = .0003) and after implementation (risk ratio 0.51; 95% CI 0.35–0.73; p = .0004). A significant Hawthorne effect was found. The accidental tube/catheter removal multifaceted safety program decreased errors significantly during implementation (odds ratio [OR] 0.34; 95% CI 0.15–0.81; p = .01]) and nonsignificantly after implementation (OR 1.65; 95% CI 0.78–3.48). The anticoagulation multifaceted safety program was not significantly effective (OR 0.64; 95% CI 0.26–1.59) but produced a significant Hawthorne effect. Conclusions: A multifaceted program was effective in preventing insulin errors and accidental tube/catheter removal. Significant Hawthorne effects occurred, emphasizing the need for appropriately designed studies before definitively implementing strategies. Trial Registration: clinicaltrails.gov Identifier: NCT00461461.





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Men More Likely Develop Mild Cognitive Problems (CME/CE)

(MedPage Today) -- Men are more likely than women to develop mild cognitive impairment, with and without memory problems, researchers found.





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Monday, January 23, 2012

Research Scientists Provide New Understanding Of Chronic Pain

Millions of people worldwide suffer from a type of chronic pain called neuropathic pain, which is triggered by nerve damage. Precisely how this pain persists has been a mystery, and current treatments are largely ineffective...





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Interest in international surgical volunteerism: results of a survey of members of the American Pedi

Publication year: 2011
Source: Journal of Pediatric Surgery, Volume 46, Issue 12, December 2011, Pages 2244-2249
Marilyn W. Butler, Sanjay Krishnaswami, David H. Rothstein, Robert A. Cusick
PurposeThis study assesses interest in international volunteer work by members of the American Pediatric Surgical Association (APSA) and attempts to identify demographics, motivations, obstacles, and institutional issues of the respondents.MethodsAn online survey service was used to send a 25-question survey to all APSA members with email addresses in November 2009. An answer to all questions was not required. Written comments were encouraged.ResultsThe survey was sent to 807 members of whom 316 responded, for a response rate of 39%. International work had been done previously by 48% of respondents, whereas 95% stated that they were interested or perhaps interested in doing so. Most (83%) were interested in operating with local surgeons to teach them how to perform procedures. Altruism was the chief motivation in 75% of respondents. Primary obstacles to doing international work were family obligations and lack of time, although 37% stated that a lack of information about volunteer opportunities was an issue. A significant number of respondents (48%) stated that their institution had no established international collaborations.ConclusionThis study suggests that there is interest in international volunteerism among many members of APSA. Understanding the issues surrounding surgical volunteerism may facilitate humanitarian involvement among pediatric surgeons.





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Third-generation CT has 100% sensitivity and specificity for identifying subarachnoid haemorrhage wh

Context

A complaint of acute onset headache mandates that subarachnoid haemorrhage (SAH) be excluded as the cause. Because of the less than perfect sensitivity of unenhanced head CT, standard practice is to follow a negative CT with lumbar puncture (LP) to exclude subarachnoid haemorrhage. Improvements in CT technology have raised the question of whether modern third-generation CT scanners are sensitive enough to adequately exclude subarachnoid haemorrhage.

Methods

This was a prospective multicentre cohort study conducted at 11 university affiliated tertiary care teaching hospitals in Canada between November 2000 and December 2009. Consecutive patients aged 15 or older who presented with acute non-traumatic headache or with syncope associated with a headache were eligible for the study. CT scans were ordered at the discretion of the treating physician. A subgroup of those patients with an interval from headache onset to CT of less than 6 h was determined...






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Clinical decision rules for the assessment of mild head injury, used in combination with clinical ju

Context

CT is currently the primary modality for investigating possible intracranial injury. The benefit of CT scanning for head injury in certain circumstances was recognised more than 30 years ago,1 but only recently have restrictive protocols based on specialist authorisation given way to a liberal approach with unrestricted access to CT scans in most high income countries. Recently, the long-term effects of radiation have been re-emphasised along with the cost of indiscriminate CT scanning, highlighting the need to determine the optimal use of CT scans for minor head injury.

Methods

In this systematic review, Pandor et al aimed to determine the most appropriate diagnostic imaging strategy for adults and children with minor Glasgow Coma Scale (GCS) 13–15 head injury through a systematic review and cost-effectiveness analysis of the current literature.

Findings

The Canadian CT Head Rule (CCHR)2 was the most...






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Intensive insulin therapy in hospitalised patients increases the risk of hypoglycaemia and has no ef

Context

Hyperglycaemia occurs in about 38% of hospitalised patients and is associated with increased morbidity, mortality and excessive cost.1–3 Earlier randomised controlled trials (RCTs), which reported improved outcome in critically ill patients treated with intensive insulin therapy (IIT),4 5 raised enthusiasm in intensive protocols aimed at correcting hyperglycaemia to normoglycaemic levels. However, recent studies have not replicated the encouraging observations of earlier RCTs6 or have indicated increased mortality7 and increased risk of severe hypoglycaemia.6–9 These studies differed with respect to study population, glycaemic targets and sampling, insulin protocols and nutritional support which could have affected their comparison with each other. A meta-analysis of 26 RCTs with pooled sample size of over 13 000 subjects found that, compared with conventional treatment, IIT resulted in a sixfold increase...






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How much of a social media profile can doctors have?

Professionalism and social media can be an uneasy mix. In the police force, Freedom of Information data have shown that, in the past four years, two officers have been sacked, seven resigned, and...





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Researchers Find Mutation Causing Neurodegeneration

A Jackson Laboratory research team led by Professor and Howard Hughes Medical Investigator Susan Ackerman, Ph.D., has discovered a defect in the RNA splicing process in neurons that may contribute to neurological disease...





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Organize your mind to organize your life

An organized mind enables full engagement in a healthy style of life. Author Margaret Moore explains how you can tap into your ability to be organized.





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Acute Effects of Nimodipine on Cerebral Vasculature and Brain Metabolism in High Grade Subarachnoid

Abstract
Background  
Nimodipine is the only medication shown to improve outcomes after aneurysmal subarachnoid hemorrhage (SAH). Preliminary theories regarding the mechanism by which it prevents vasospasm have been challenged. The acute physiologic and metabolic effects of oral Nimodipine have not been examined in patients with poor-grade SAH.
Methods  
This is an observational study performed in 16 poor-grade SAH patients undergoing multimodality monitoring who received oral Nimodipine as part of routine clinical care. A total of 663 doses of Nimodipine were observed. Changes in physiologic measurements including MAP, CPP, ICP, PbtO2, and CBF were examined.
Results  
Administration of oral Nimodipine was associated with a 1.33 mmHg decrease in MAP (P < 0.001) and a 1.22 mmHg decrease in CPP (P < 0.001). When administration of Nimodipine was associated with MAP decreases, PbtO2 (1.03 mmHg; P < 0.001) and CBF (0.39 ml/100 g/min; P = 0.002) also decreased.
Conclusions  
Despite CPP targeted therapy with vasopressor medication, oral Nimodipine was associated with a decrease in MAP and CPP. When Nimodipine administration was associated with a decrease in MAP, there were concomitant drops in PbtO2 and CBF. These findings suggest that MAP support after oral Nimodipine may be important to maintain adequate CBF in patients with poor-grade subarachnoid hemorrhage.

  • Content Type Journal Article
  • Pages 1-5
  • DOI 10.1007/s12028-012-9670-8
  • Authors
    • H. Alex Choi, Division of Neurocritical Care, The Neurologic Institute of New York, Columbia University College of Physicians and Surgeons, Milstein Hospital Building 8 Center, 177 Fort Washington Ave, New York, NY 10032, USA
    • Sang-Bae Ko, Division of Neurocritical Care, The Neurologic Institute of New York, Columbia University College of Physicians and Surgeons, Milstein Hospital Building 8 Center, 177 Fort Washington Ave, New York, NY 10032, USA
    • Huahiou Chen, Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
    • Emily Gilmore, Division of Neurocritical Care, The Neurologic Institute of New York, Columbia University College of Physicians and Surgeons, Milstein Hospital Building 8 Center, 177 Fort Washington Ave, New York, NY 10032, USA
    • Amanda M. Carpenter, Division of Neurocritical Care, The Neurologic Institute of New York, Columbia University College of Physicians and Surgeons, Milstein Hospital Building 8 Center, 177 Fort Washington Ave, New York, NY 10032, USA
    • Danielle Lee, Division of Neurocritical Care, The Neurologic Institute of New York, Columbia University College of Physicians and Surgeons, Milstein Hospital Building 8 Center, 177 Fort Washington Ave, New York, NY 10032, USA
    • Jan Claassen, Division of Neurocritical Care, The Neurologic Institute of New York, Columbia University College of Physicians and Surgeons, Milstein Hospital Building 8 Center, 177 Fort Washington Ave, New York, NY 10032, USA
    • Stephan A. Mayer, Division of Neurocritical Care, The Neurologic Institute of New York, Columbia University College of Physicians and Surgeons, Milstein Hospital Building 8 Center, 177 Fort Washington Ave, New York, NY 10032, USA
    • J. Michael Schmidt, Division of Neurocritical Care, The Neurologic Institute of New York, Columbia University College of Physicians and Surgeons, Milstein Hospital Building 8 Center, 177 Fort Washington Ave, New York, NY 10032, USA
    • Kiwon Lee, Division of Neurocritical Care, The Neurologic Institute of New York, Columbia University College of Physicians and Surgeons, Milstein Hospital Building 8 Center, 177 Fort Washington Ave, New York, NY 10032, USA
    • E. Sander Connelly, Department of Neurosurgery, The Neurologic Institute of New York, Columbia University College of Physicians and Surgeons, New York, NY, USA
    • Myunghee Paik, Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
    • Neeraj Badjatia, Division of Neurocritical Care, The Neurologic Institute of New York, Columbia University College of Physicians and Surgeons, Milstein Hospital Building 8 Center, 177 Fort Washington Ave, New York, NY 10032, USA





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Neuroendoscopic management of posterior third ventricle and pineal region tumors: technique, limitat

Abstract  
The endoscopic approach has gained an increased popularity in recent years for the biopsy and, in selected cases, the removal of tumors of the posterior third ventricle and pineal region. The authors report their experience on a series of 20 patients discussing also the technical limitations and complication avoidance. This is a prospective study of 20 patients with posterior third ventricle and pineal region tumors surgically managed by endoscopic biopsy and/or excision and simultaneous third ventriculostomy. The removal of the lesion could be achieved in 12 cases whereas in 8, only a biopsy could be performed. A histological diagnosis could be obtained in all cases. No delayed third ventricular stoma failures were recorded in any patient at the latest follow-up (mean follow-up, 39 months). Severe postoperative complications were recorded in 2 out of 12 cases of tumor removal attempt and in zero out of eight cases of biopsy. A delayed (3 weeks) postoperative mortality occurred in a patient harboring a GBM that developed an intratumoral hematoma 48 h postoperatively, one patient was in a vegetative state. Transient postoperative complications included: nausea and vomiting (five cases) and diplopia (two cases). One patient developed a bilateral ophthalmoplegia that recovered within 6 months due to residual tumor hemorrhage. Higher rate of complications was found in the case of vascularized and/or larger lesions. Endoscopic management of posterior third ventricle lesions may represent an effective option. However, though biopsies remain often a safe procedure, tumor excision should be limited to highly selected cases (cystic, poorly vascularized, and/or smaller than 2.5-cm lesions).

  • Content Type Journal Article
  • Category Original Article
  • Pages 1-10
  • DOI 10.1007/s10143-011-0370-1
  • Authors
    • S. Chibbaro, Department of Neurosurgery, Lariboisiere University Hospital, Paris, France
    • F. Di Rocco, Department of Neurosurgery, Necker University Hospital, Paris, France
    • O. Makiese, Department of Neurosurgery, Lariboisiere University Hospital, Paris, France
    • A. Reiss, Department of Neurosurgery, Lariboisiere University Hospital, Paris, France
    • P. Poczos, Department of Neurosurgery, Lariboisiere University Hospital, Paris, France
    • G. Mirone, Department of Neurosurgery, Lariboisiere University Hospital, Paris, France
    • F. Servadei, Department of Neurosurgery, Parma University Hospital, Parma, Italy
    • B. George, Department of Neurosurgery, Lariboisiere University Hospital, Paris, France
    • P. Crafa, Department of Histopathology, Parma University Hospital, Parma, Italy
    • M. Polivka, Department of Histopathology, Lariboisiere University Hospital, Paris, France
    • A. Romano, Department of Neurosurgery, Parma University Hospital, Parma, Italy





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Saturday, January 21, 2012

Risk factors of sudden death in young adult patients with myelomeningocele

Journal of Neurosurgery: Pediatrics, Volume 9, Issue 2, Page 149-155, February 2012.
Object Although survival for patients with myelomeningocele has dramatically improved in recent decades, the occasional occurrence of sudden, unexplained death in young adult patients with myelomeningocele has been noted by the authors. This study was undertaken to determine risk factors for sudden death in this population. Methods The authors performed a retrospective chart review of patients born between 1978 and 1990 who received care at Children's Hospital Boston. The relationship between sudden death and patient demographics, presence of CSF shunt and history of shunt revisions, midbrain length as a marker for severity of hindbrain malformation, seizures, pulmonary and ventilatory dysfunction, body mass index, scoliosis, renal dysfunction, and cardiac disease was evaluated using the t-test, Fisher exact test, and logistic regression analysis. Results The age range for 106 patients in the study cohort was 19–30 years, with 58 (54.7%) women and 48 (45.3%) men. Six patients, all of whom were young women, experienced sudden death. In multivariate analysis, female sex, sleep apnea, and midbrain elongation ≥ 15 mm on MR imaging remained significantly associated with a higher risk of sudden death. These risk factors were cumulative, and female patients with sleep apnea and midbrain length ≥ 15 mm had the greatest risk (adjusted risk ratio 24.0, 95% CI 7.3–79.0; p < 0.05). No other comorbidities were found to significantly increase the risk of sudden death. Conclusions Young adult women with myelomeningocele are at significantly increased risk of sudden death in the setting of midbrain elongation and sleep apnea. Further investigation is needed to determine the benefit of routine screening to identify at-risk patients for closer cardiopulmonary monitoring and treatment.





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Edema and elasticity of a fronto-temporal decompressive craniectomy

Daikei Takada, Hidemasa Nagai, Kouzo Moritake, Yasuhiko Akiyama

Surgical Neurology International 2012 3(1):11-11

Background: Decompressive craniectomy is undertaken for relief of brain herniation caused by acute brain swelling. Brain stiffness can be estimated by palpating the decompressive cranial defect and can provide some relatively subjective information to the neurosurgeon to help guide care. The goal of the present study was to objectively evaluate transcutaneous stiffness of the cranial defect using a tactile resonance sensor and to describe the values in patients with a decompressive window in order to characterize the clinical association between brain edema and stiffness. Methods: Data were prospectively collected from 13 of 37 patients who underwent a decompressive craniectomy in our hospital during a 5-year period. Transcutaneous stiffness was measured as change in frequency and as elastic modulus. Results: Stiffness variables of the decompressive site were measured without any adverse effect and subsequent calculations revealed change in frequency = 101.71 &#177; 36.42 Hz, and shear elastic modulus = 1.99 &#177; 1.11 kPa. Conclusions: The elasticity of stiffness of a decompressive site correlated with brain edema, cisternal cerebrospinal fluid pressure, and brain shift, all of which are related to acute brain edema.





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Effects of intrathecal baclofen therapy on motor and cognitive functions in a rat model of cerebral

Journal of Neurosurgery: Pediatrics, Volume 9, Issue 2, Page 209-215, February 2012.
Object Cerebral palsy (CP) arises in the early stages of brain development and manifests as spastic paresis that is often associated with cognitive dysfunction. Available CP treatments are aimed at the management of spasticity and include botulinum toxin administration, selective dorsal rhizotomy, and intrathecal baclofen (ITB). In this study, the authors investigated whether the management of spasticity with ITB therapy affected motor function and whether the release of spasticity was associated with an improvement in intellectual function. Methods Newborn Sprague-Dawley rats were divided into the following groups: control, CP model, and CP model with ITB therapy. For the CP model, postnatal Day 7 (P7) rats were exposed to hypoxic conditions (8% O2) for 150 minutes after ligation of the right common carotid artery. In the groups receiving ITB therapy, a spinal catheter was connected to an osmotic pump filled with baclofen and placed in the spinal subarachnoid space on P21 in the early group and on P35 in the late group. A daily dose of 12 μg of baclofen was continuously administered until P49, resulting in 28 days of therapy in the early group and 14 days in the late group. Changes in spasticity in the CP and CP with ITB treatment groups were confirmed by assessing the motor evoked potential in the plantar muscle. Results In the CP group, the time required to complete a beam-walking test on P49 was significantly longer than that in the control and ITB treatment groups (4.15 ± 0.60 vs 2.10 ± 0.18 and 2.22 ± 0.22 seconds, respectively). Results of the beam-walking test are expressed as the mean ± SD. Radial arm maze performance on P49 indicated that spatial reference memory had significantly deteriorated in the CP group compared with controls (2.33 ± 0.87 vs 0.86 ± 0.90 points); moreover, working memory was also negatively affected by CP (0.78 ± 1.09 vs 0.14 ± 0.38 points). Results of the memory tests are expressed as the mean ± SE. These memory functions did not recover after ITB treatment. Conclusions Management of spasticity with ITB therapy improved the walking ability in the rat CP model. Intrathecal baclofen therapy—which reduces harmful sensory and motor stimulations caused by spasticity to more optimal levels—contributed to motor function recovery; however, it had no effect on intellectual recovery as assessed by memory performance in the rat CP model.





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Clinical and radiographic evaluation of posterior surgical correction for the treatment of moderate

Journal of Neurosurgery: Spine, Volume 0, Issue 0, Page 1-8, Ahead of Print.
Object The object of this study was to compare the clinical and radiographic outcomes of 36 patients with posttuberculosis kyphosis who underwent one of two types of osteotomy. Methods Each patient underwent single-stage correction via a posterior surgical approach. A modified pedicle subtraction osteotomy (mPSO) was performed when the kyphotic deformity was less than 70° (7 cases), whereas a posterior vertebral column resection (VCR) was performed when the kyphotic deformity exceeded 70° (29 cases). Full-length standing radiographs were obtained before surgery and at follow-up visits. These images were used to measure the kyphosis angle; sagittal alignment of the lumbar, thoracic, and cervical regions; and sagittal balance of the spine. Back pain was rated using the visual analog scale (VAS), and neurological function was classified based on the American Spinal Injury Association (ASIA) grading system. Each patient's overall satisfaction with surgical treatment was measured with the Patient Satisfaction Index. For purposes of comparison, patients were studied in 2 groups based on the region of their kyphotic apex. Half of the cohort had apical kyphosis in the lower thoracic spine or thoracolumbar junction (TL group). Using both radiographic and clinical assessments, the authors compared this group with the other half of the patients who had apical kyphosis in the upper to mid thoracic spine (MT group). Results The cohort included 15 males and 21 females, with an average age of 34 years at the time of surgery. The minimum follow-up was 24 months, and the mean follow-up was 31 months. Following surgery, kyphosis across the treated segments was reduced by an average of 60°. Lumbar lordosis also improved by an average of 24°, and thoracic kyphosis improved by an average of 20°. Both back pain and neurological function improved after surgical treatment. There was a 67% improvement in VAS scores, and 13 of the 36 patients had improvement in their ASIA grade. The 2 surgical procedures used for deformity correction (mPSO and VCR) demonstrated comparable radiographic and clinical results. Note, however, that differences were found in both radiographic and clinical outcomes in comparing patients who had lower thoracic or thoracolumbar (TL group) versus upper to midthoracic (MT group) apical kyphosis. Conclusions Posterior tubercular kyphosis can be effectively improved through corrective surgery, and deformity correction can be accompanied by improvement in clinical symptoms. When appropriately selected, both the mPSO and the VCR can be expected to yield satisfactory reduction of post-tuberculosis kyphotic deformities. Differences in radiographic and clinical outcomes should be anticipated, however, when treating such deformities in different regions of the spine.





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Natural history and imaging prevalence of cavernous malformations in children and young adults

Journal of Neurosurgery: Pediatrics, Volume 9, Issue 2, Page 198-205, February 2012.
Object This study was undertaken to define the age-related prevalence of cavernous malformations (CMs) in children and young adults undergoing intracranial imaging. In addition, the authors aim to clarify the natural history of CMs in young people, especially in those with incidentally discovered lesions. Methods To identify those patients with CMs, the authors retrospectively reviewed the electronic medical records of 14,936 consecutive patients 25 years of age or younger who had undergone brain MR imaging. In patients with a CM, clinical and imaging data were collected. Patients with untreated cavernomas who had more than 6 months of clinical and MR imaging follow-up were included in a natural history analysis. The natural history analysis included 110 CMs in 56 patients with a 3.5-year mean clinical follow-up interval (199 patient-years and 361 cavernoma-years). Results In 92 patients (0.6%), 164 CMs were identified. The imaging prevalence of cavernomas increased with advancing age (p = 0.002). Multiple CMs occurred in 28 patients (30%), and 8 patients (9%) had a family history of multiple CMs. Fifty patients (54%) presented with symptoms related to the cavernoma, of whom 30 presented with hemorrhage (33%). Of the 164 cavernomas identified, 103 (63%) were considered incidental, asymptomatic lesions. Larger size was associated with acute symptomatic presentation (p = 0.0001). During the follow-up interval, 6 patients with 8 cavernomas developed 11 symptomatic hemorrhages after initial identification. Five of the patients who had a hemorrhage during the follow-up interval had initially presented with hemorrhage, while only 1 had presented incidentally. The hemorrhage rate for all patients in the natural history group was 1.6% per patient-year and 0.9% per cavernoma-year. The hemorrhage rate was 8.0% per patient-year in the symptomatic group versus 0.2% in the incidental group. Symptomatic hemorrhage after long-term follow-up was associated with initial acute presentation (p = 0.02). Conclusions The imaging prevalence of CM increases with advancing age during childhood. Patients presenting without hemorrhage have a significantly lower risk of bleeding compared with those who present with acute neurological symptoms. Comparing this series of children to prior analyses of CM natural history in adults, the authors' data do not suggest a higher bleeding risk in younger patients.





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Pediatric orbital schwannoma originating from the oculomotor nerve

Journal of Neurosurgery: Pediatrics, Volume 9, Issue 2, Page 165-168, February 2012.
Intraorbital schwannoma is a rare tumor that constitutes approximately 1%–8% of all orbital tumors. The authors report a case of orbital schwannoma in a 5-year-old boy who was admitted to their institute with exophthalmos and ptosis of the right eye. Computed tomography scanning and MR imaging revealed a retroocular mass in the right orbit. The tumor was successfully removed via a transcranial approach. The pathological diagnosis was schwannoma that appeared to originate from the superior branch of the oculomotor nerve. Despite the rarity of these intraorbital extraocular tumors in children, schwannomas should be differentiated from other intraorbital tumors.





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Posterior fossa epidural hematomas in children: clinical experience with 40 cases

Journal of Neurosurgery: Pediatrics, Volume 9, Issue 2, Page 139-143, February 2012.
Object Traumatic posterior fossa epidural hematoma (PFEDH) is rare, but among children it may have a slightly higher incidence. With the widespread use of CT scanning, the diagnosis of PFEDH can be established more accurately, leading to an increased incidence of the lesion and possibly to a better patient prognosis. This study presents 40 pediatric cases with PFEDH. Methods The authors assessed the type of trauma, clinical findings on admission, Glasgow Coma Scale scores, CT findings (thickness of the hematoma, bone fracture, compression of the fourth ventricle, and ventricle enlargement), type of treatment, clinical course, and prognosis. Early postoperative CT scans (within the first 6 hours) were obtained and reviewed in all surgical cases. Results Twenty-nine patients underwent surgery and 11 patients received conservative therapy and close follow-up. All patients fared well, and there was no surgical mortality or morbidity. Conclusions Based on the data in this large series, the authors conclude that PFEDH in children can be treated in experienced centers with excellent outcome, and there is no need to avoid surgery when it is indicated.





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Comparison of outcomes following decompressive craniectomy in children with accidental and nonaccide

Journal of Neurosurgery: Pediatrics, Volume 9, Issue 2, Page 125-132, February 2012.
Object The goal of this study was to compare clinical outcomes following decompressive craniectomy performed for intracranial hypertension in children with nonaccidental, blunt cranial trauma with outcomes of decompressive craniectomy in children injured by other mechanisms. Methods All children in a prospectively acquired database of trauma admissions who underwent decompressive craniectomy over a 9-year span, beginning January 1, 2000, are the basis for this study. Clinical records and neuroimaging studies were systematically reviewed. Results Thirty-seven children met the inclusion criteria. Nonaccidental head trauma was the most common mechanism of injury (38%). The mortality rate in patients with abusive brain injury (35.7%) was significantly higher (p < 0.05) than in patients with other causes of traumatic brain injury (4.3%). Children with inflicted head injuries had a 12-fold increase in the odds of death and 3-fold increase in the odds of a poor outcome (King's Outcome Scale for Closed Head Injury score of 1, 2, or 3). Conclusions Children with nonaccidental blunt cranial trauma have significantly higher mortality following decompressive craniectomy than do children with other mechanisms of injury. This understanding can be interpreted to mean either that the threshold for decompression should be lower in children with nonaccidental closed head injury or that decompression is unlikely to alter the path to a fatal outcome. If decompressive craniectomy is to be effective in reducing mortality in the setting of nonaccidental blunt cranial trauma, it should be done quite early.





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Surgical checklists: A detailed review of their emergence, development, and relevance to neurosurgic

Douglas J McConnell, Kyle M Fargen, J Mocco

Surgical Neurology International 2012 3(1):2-2

In the fall of 1999, the Institute of Medicine released "To Err is Human: Building a Safer Health System," a sobering report on the safety of the American healthcare industry. This work and others like it have ushered in an era where the science of quality assurance has quickly become an integral facet of the practice of medicine. One critical component of this new era is the development, application, and refinement of checklists. In a few short years, the checklist has evolved from being perceived as an assault on the practitioners' integrity to being welcomed as an important tool in reducing complications and preventing medical errors. In an effort to further expand the neurosurgical community's acceptance of surgical checklists, we review the rationale behind checklists, discuss the history of medical and surgical checklists, and remark upon the future of checklists within our field.





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Safety and efficacy of sildenafil citrate in reversal of cerebral vasospasm: A feasibility study

Kanchan K Mukherjee, Shrawan K Singh, Virender K Khosla, Sandeep Mohindra, Pravin Salunke

Surgical Neurology International 2012 3(1):3-3

Objective: Cerebral vasospasm is the commonest cause for mortality and morbidity in patients following clipping of a ruptured aneurysm. Selective phosphodiesterase (PDE) inhibitor like sildenafil acts as a vasodilator. The objective of this study was to evaluate the safety and feasibility of oral sildenafil citrate in patients with symptomatic refractory vasospasm. Methods: A total of 832 patients with aneurysmal subarachnoid bleed were operated in 4 years. Two hundred and seventy-three patients had vasospasm. Of these, 72 patients had refractory cerebral vasospasm. Vasospasm was defined as "refractory" when institution of "HHH" failed to reverse the transcranial Doppler (TCD) values even after 24 hours. Computed tomography (CT) scan showed no infarct, hematoma, or hydrocephalus, and the serum electrolytes were within normal limits. They received 100-150 mg of sildenafil every 4 hours. Response was evaluated by 2-hourly TCD. Results: Eight patients had sustained (TCD values normal for >48 hours) and four had temporary relief in vasospasm, as suggested. Four patients developed complications significant enough to terminate the therapy. Conclusions: Sildenafil citrate may be effective in patients with refractory symptomatic vasospasm. It calls upon the pharmacologists and scientists to discover newer supraselective PDE inhibitors, specific to PDE receptors in brain vessels.





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Endovascular embolization of carotid-cavernous fistulas: A pioneering experience in Peru

Andres R Plasencia, Alejandro Santillan

Surgical Neurology International 2012 3(1):5-5

Background: Endovascular embolization represents the method of choice for the treatment of carotid-cavernous fistulas (CCFs). Methods: We report our experience using the endovascular technique in 24 patients harboring 25 CCFs treated between October 1994 and April 2010, with an emphasis on the role of detachable balloons for the treatment of direct CCFs. Results: Of the 16 patients who presented with direct CCFs (Barrow Type A CCFs) (age range, 7-62 years; mean age, 34.3 years), 14 were caused by traumatic injury and 2 by a ruptured internal carotid artery (ICA) aneurysm. Eight patients (age range, 32-71 years; mean age, 46.5 years) presented with nine indirect CCFs (Barrow Types B, C, and D). The clinical follow-up after endovascular treatment ranged from 2 to 108 months (mean, 35.2 months). In two cases (8%), the endovascular approach failed. Symptomatic complications related to the procedure occurred in three patients (12.5%): transient cranial nerve palsy in two patients and a permanent neurological deficit in one patient. Detachable balloons were used in 13 out of 16 (81.3%) direct CCFs and were associated with a cure rate of 92.3%. Overall, the angiographic cure rate was obtained in 22 out of 25 (88%) fistulas. Patients presenting with III nerve palsy improved gradually between 1 day and 6 months after treatment. Good clinical outcomes [modified Rankin scale (mRS) &#8804; 2] were observed in 22 out of 24 (91.6%) patients at last follow-up. Conclusions: Endovascular treatment using detachable balloons still constitutes a safe and effective method to treat direct carotid-cavernous fistulas.





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Early microsurgical treatment for spinal hemangioblastomas improves outcome in patients with von Hip

Ali Harati, Jarno Satopää, Lydia Mahler, Romain Billon-Grand, Ahmed Elsharkawy, Mika Niemelä, Juha Hernesniemi

Surgical Neurology International 2012 3(1):6-6

Background: Spinal hemangioblastomas (HB) are rare, histologically benign, highly vascularized tumors often associated with von Hippel-Lindau (VHL) disease. The aim of the current study is to demonstrate the benefit of early surgical resection of large spinal HBs in selected asymptomatic patients with VHL. Methods: Seventeen patients underwent microsurgical resection of 20 spinal HBs at the Department of Neurosurgery at Helsinki University Central Hospital (HUCH). Thirteen tumors were in the cervical spine, five in thoracic and one patient had two lumbar lesions. MRI tumor showed an associated syrinx in 16 patients (94%). Tumor volume ranged from 27 to 2730 mm3 . Out of 17 patients, 11 (65%) tested positive for VHL in mutation analysis. Five of these patients with tumors ranging from 55 to 720 mm3 were treated prophylactically. Results: Complete tumor resection was performed in 16 patients (94%) who were followed up for a median of 57 months (range 2-165 months). No patient had neurological decline on long-term follow-up. Among the patients with VHL, five patients with preoperative sensorimotor deficits showed improvement of their symptoms but never regained full function. One patient who presented with tetraplegia remained the same. Otherwise, all five patients with prophylactic surgery remained neurologically intact. Conclusion: Although documented growth on serial MRIs and the need for pathological diagnosis have been suggested as indications for surgery in otherwise asymptomatic patients, our series showed that a potentially larger group of asymptomatic patients with spinal HB associated with VHL would benefit from microsurgical resection. Long-term results of the surgical management of spinal HB are generally favorable. Our results suggest staging and early treatment for spinal HB larger than 55 mm3 , especially in patients with VHL. Small spinal HBs may be followed up.





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