RESUMEN
OBJECTIVE: The authors evaluated the sensitivity and selectivity of interictal magnetoencephalography (MEG) versus prolonged ictal and interictal scalp video-electroencephalography (V-EEG) in order to identify patient groups that would benefit from preoperative MEG testing. METHODS: The authors evaluated 113 consecutive patients with medically refractory epilepsy who underwent surgery. The epileptogenic region predicted by interictal and ictal V-EEG and MEG was defined in relation to the resected area as perfectly overlapping with the resected area, partially overlapping, or nonoverlapping. RESULTS: The sensitivity of a 30-minute interictal MEG study for detecting clinically significant epileptiform activity was 79.2%. Using MEG, we were able to localize the resected region in a greater proportion of patients (72.3%) than with noninvasive V-EEG (40%). MEG contributed to the localization of the resected region in 58.8% of the patients with a nonlocalizing V-EEG study and 72.8% of the patients for whom V-EEG only partially identified the resected zone. Overall, MEG and V-EEG results were equivalent in 32.3% of the cases, and additional localization information was obtained using MEG in 40% of the patients. CONCLUSION: MEG is most useful for presurgical planning in patients who have either partially or nonlocalizing V-EEG results.
Asunto(s)
Electroencefalografía/métodos , Epilepsia/diagnóstico , Epilepsia/cirugía , Magnetoencefalografía , Potenciales de Acción , Adolescente , Adulto , Niño , Preescolar , Electroencefalografía/instrumentación , Epilepsia/complicaciones , Femenino , Humanos , Lactante , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Cuidados Preoperatorios/instrumentación , Cuidados Preoperatorios/métodos , Reproducibilidad de los Resultados , Convulsiones/diagnóstico , Convulsiones/etiología , Sensibilidad y EspecificidadRESUMEN
The presentation of anaplastic large cell lymphoma in bone is uncommon. We report a case of anaplastic large cell lymphoma of the skull that was diagnosed after head trauma. Biopsy revealed significant destruction of the outer table of the frontal bone. Histopathologically, the initial evaluation suggested osteomyelitis because of a mixed inflammatory infiltrate with large numbers of neutrophils. However, several clusters and individual mononuclear cells were atypical. The tumor cells had large, pleomorphic nuclei; these cells stained positively with antibodies to Ki-1 (CD 30), ALK-1, and EMA. Fluorescence in situ hybridization (FISH) showed rearrangement of the ALK gene, which usually results from the t(2;5) translocation, present in most anaplastic large cell lymphomas. There was no evidence of systemic disease. The patient has tolerated chemotherapy and is free of disease 12 months later.
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Traumatismos Craneocerebrales , Antígeno Ki-1 , Linfoma Anaplásico de Células Grandes/patología , Neutrófilos/patología , Neoplasias Craneales/patología , Receptores de Activinas , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Núcleo Celular/química , Núcleo Celular/genética , Núcleo Celular/patología , Niño , ADN de Neoplasias/análisis , Factor de Transcripción E2F6 , Humanos , Inmunohistoquímica , Hibridación Fluorescente in Situ , Antígeno Ki-1/análisis , Linfoma Anaplásico de Células Grandes/química , Linfoma Anaplásico de Células Grandes/tratamiento farmacológico , Linfoma Anaplásico de Células Grandes/genética , Masculino , Proteínas Serina-Treonina Quinasas/análisis , Proteínas Serina-Treonina Quinasas/genética , Proteínas Represoras/análisis , Neoplasias Craneales/química , Neoplasias Craneales/tratamiento farmacológico , Neoplasias Craneales/genética , Factores de Transcripción/análisisRESUMEN
BACKGROUND: Infants and children cool quickly because their surface area (and therefore heat loss) is large compared with their metabolic rate, which is mostly a function of body mass. Rewarming rate is a function of cutaneous heat transfer plus metabolic heat production divided by body mass. Therefore, the authors tested the hypothesis that the rate of forced-air rewarming is inversely related to body size. METHODS: Isoflurane, nitrous oxide, and fentanyl anesthesia were administered to infants, children, and adults scheduled to undergo hypothermic neurosurgery. All fluids were warmed to 37 degrees C and ambient temperature was maintained near 21 degrees C. Patients were covered with a full-body, forced-air cover of the appropriate size. The heater was set to low or ambient temperature to reduce core temperature to 34 degrees C in time for dural opening. Blower temperature was then adjusted to maintain core temperature at 34 degrees C for 1 h. Subsequently, the forced-air heater temperature was set to high (approximately 43 degrees C). Rewarming continued for the duration of surgery and postoperatively until core temperature exceeded 36.5 degrees C. The rewarming rate in individual patients was determined by linear regression. RESULTS: Rewarming rates were highly linear over time, with correlations coefficients (r2) averaging 0.98+/-0.02. There was a linear relation between rewarming rate (degrees C/h) and body surface area (BSA; m2): Rate (degrees C/h) = -0.59 x BSA (m2) + 1.9, r2 = 0.74. Halving BSA thus nearly doubled the rewarming rate. CONCLUSIONS: Infants and children rewarm two to three times faster than adults, thus rapidly recovering from accidental or therapeutic hypothermia.
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Superficie Corporal , Peso Corporal/fisiología , Recalentamiento , Adulto , Niño , Preescolar , Femenino , Humanos , Hipotermia Inducida , Lactante , Masculino , Persona de Mediana Edad , Procedimientos NeuroquirúrgicosRESUMEN
In this report, the newest of the functional imaging methods, magnetoencephalography, is described, and its use in addressing the issue of brain reorganization for basic sensory and linguistic functions is documented in a series of 10 children and young adults. These patients presented with a wide variety of conditions, ranging from tumors and focal epilepsy to reading disability. In all cases, clear evidence of reorganization of the brain mechanisms of either somatosensory or linguistic functions or both was obtained, demonstrating the utility of magnetoencephalography in studying, completely noninvasively, the issue of plasticity in the developing brain.
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Encéfalo/crecimiento & desarrollo , Lingüística , Magnetoencefalografía , Plasticidad Neuronal/fisiología , Adolescente , Adulto , Percepción Auditiva , Neoplasias Encefálicas/patología , Niño , Dislexia/patología , Epilepsia/patología , Potenciales Evocados Somatosensoriales , Femenino , Humanos , Masculino , Percepción VisualRESUMEN
This study evaluated the validity of data derived from magnetic source imaging regarding hemispheric dominance for language in children and adolescents with intractable seizure disorder by comparison with results of the intracarotid amobarbital procedure. Functional imaging of the receptive language cortex using a whole-head neuromagnetometer was performed in 19 consecutive epilepsy patients, ages 8 to 18 years, who also underwent the intracarotid amobarbital procedure. During magnetic source imaging recordings, patients engaged in a continuous recognition memory task for words in visual and auditory modalities. This task has previously been shown to be valid for the purpose of lateralization and localization of language cortex in adult epilepsy patients who undergo the intracarotid amobarbital procedure and intraoperative language mapping allowing confirmation of magnetic source imaging findings. Results indicated that language laterality indices formed for the intracarotid amobarbital procedure and magnetic source imaging procedures were highly correlated (R = .87). In addition, clinical judgments regarding cerebral dominance for language made by independent raters using the two methods were in excellent agreement. We conclude that magnetic source imaging is a promising method for determination of cerebral dominance for language in children and adults.
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Amobarbital , Mapeo Encefálico/métodos , Dominancia Cerebral , Epilepsia/psicología , Moduladores del GABA , Lenguaje , Magnetoencefalografía , Adolescente , Niño , Potenciales Evocados , Femenino , Humanos , Inyecciones Intraarteriales , Masculino , Pruebas Neuropsicológicas , Valor Predictivo de las PruebasRESUMEN
To identify factors influencing outcome and morbidity in patients selected for corpus callosotomy, we retrospectively reviewed 23 patients with intractable generalized seizures who underwent corpus callosotomy between 1991 and 1994. Three patients had a complete corpus callosotomy, while 20 had an anterior callosotomy. Three of those patients subsequently had completion of the anterior callosotomy. Overall, 41% of patients were nearly or completely free of the seizure types targeted for surgical treatment, while another 45% had seizures less than half as frequently. Four patients developed simple partial motor seizures after callosotomy. A transient disconnection syndrome was observed in 57% of patients. The best predictor of good outcome was a normal preoperative MRI. Mentally retarded patients had poorer outcomes. Outcome was not predicted by extent of callosal section or lateralization on neurological examination, EEG, MRI, and SPECT. Completion of anterior callosotomy resulted in significant reductions in seizure frequency. Though most patients do not become seizure-free after corpus callosotomy, worthwhile palliation of an otherwise intractable illness can be achieved. An analysis of prognostic factors should lead to better selection of patients for surgery.
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Cuerpo Calloso/cirugía , Epilepsia/cirugía , Adolescente , Adulto , Anticonvulsivantes/uso terapéutico , Niño , Preescolar , Epilepsia/complicaciones , Epilepsia/tratamiento farmacológico , Humanos , Complicaciones Posoperatorias , Recurrencia , Estudios Retrospectivos , Estado Epiléptico/cirugía , Resultado del TratamientoRESUMEN
The role of surgery in the treatment of refractory epilepsy (RE) in tuberous sclerosis complex (TSC) is poorly defined. Four patients with RE and TSC were evaluated for epilepsy surgery from 1994 to 1996. Three of four patients developed infantile spasms within 5 months of birth. These progressed to frequent complex partial and generalized tonic/myoclonic seizures refractory to antiepileptic drug therapy. Neuroimaging revealed typical findings of TSC including calcified lesions consistent with hamartomas. Clinical and EEG evidence suggested an epileptic focus near a prominent lesion in each child. This was confirmed using magnetic source imaging in 1 case. All patients underwent inpatient continuous video-EEG monitoring followed by temporal lobectomy or focal cortical resection with intraoperative EEG. Age at operation ranged from 5 to 13 years. Three out of 4 patients experienced a greater than 90% decrease in seizure activity. One patient continues to have rare complex partial seizures, and 1 has rare simple partial seizures. Tumor DNA analysis revealed mutations in the TSC1 gene in case 1 and the TSC2 gene in case 2; no mutations have been identified yet in cases 3 and 4. Temporal lobectomy and focal cortical resection can result in improved seizure control in patients with TSC and RE.
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Epilepsia/cirugía , Esclerosis Tuberosa/cirugía , Adolescente , Corteza Cerebral/cirugía , Niño , Preescolar , Cromosomas Humanos Par 16 , Cromosomas Humanos Par 9 , Electroencefalografía , Epilepsia/diagnóstico , Epilepsia/etiología , Epilepsia/genética , Femenino , Expresión Génica/fisiología , Humanos , Imagen por Resonancia Magnética , Magnetoencefalografía , Masculino , Monitoreo Fisiológico , Proteínas/genética , Psicocirugía , Proteínas Represoras/genética , Resultado del Tratamiento , Esclerosis Tuberosa/complicaciones , Esclerosis Tuberosa/diagnóstico , Esclerosis Tuberosa/genética , Proteína 1 del Complejo de la Esclerosis Tuberosa , Proteína 2 del Complejo de la Esclerosis Tuberosa , Proteínas Supresoras de TumorRESUMEN
Pediatric meningiomas are rare. They are usually seen in association with neurofibromatosis type 2 (NF-2) or following radiation therapy. The tumors are more frequently intraventricular, cystic, and infratentorial than are those in adult patients. Pathologically they are more histologically aggressive than in adults and tend to recur more frequently. Complete resection is the surgical goal. The treatment of subtotally resected meningiomas, particularly in NF-2, remains controversial.
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Neoplasias Meníngeas/epidemiología , Meningioma/epidemiología , Adolescente , Niño , Preescolar , Femenino , Humanos , Masculino , Neoplasias Meníngeas/patología , Neoplasias Meníngeas/cirugía , Meningioma/patología , Meningioma/cirugía , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
The effects of early hydrocephalus and related brain anomalies on cognitive skills are not well understood. In this study, magnetic resonance scans were obtained from 99 children aged from 6 to 13 years with either shunted hydrocephalus (n = 42) or arrested (unshunted) hydrocephalus (n = 19), from patient controls with no hydrocephalus (n = 23), and from normal, nonpatient controls (n = 15). Lateral ventricle volumes and area measurements of the internal capsules and centra semiovale in both hemispheres were obtained from these scans, along with area measurements of the corpus callosum. Results revealed reductions in the size of the corpus callosum in the shunted hydrocephalus group. In addition, lateral ventricle volumes were larger and internal capsule areas were smaller in both hemispheres in children with shunted and arrested hydrocephalus. The centra semiovale measurements did not differentiate the groups. Correlating these measurements with concurrent assessments of verbal and nonverbal cognitive skills, motor abilities, and executive functions revealed robust relationships only between the area of the corpus callosum and nonverbal cognitive skills and motor abilities. These results support the theory of a prominent role for the corpus callosum defects characteristic of many children with shunted hydrocephalus in the spatial cognition deficits commonly observed in these children.
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Encéfalo/patología , Desarrollo Infantil , Cognición , Hidrocefalia/diagnóstico , Hidrocefalia/psicología , Ventrículos Cerebrales/patología , Niño , Femenino , Humanos , Imagen por Resonancia Magnética , MasculinoRESUMEN
Hemangiopericytomas (HPs) are rare tumors, about 10% of which occur in children. Since 1988, 2 children with intracranial HP have been seen at the University of Texas M.D. Anderson Cancer Center. The patients presented at ages 2 weeks and 1 month. Both were treated with surgery alone. We also review 4 cases previously reported in the literature; at presentation, those patients were ages 2 days to 9 months. Infantile HPs have a better prognosis than do those that occur in adults, and an improved outcome is also evident for intracranial lesions. Tumors that occur in the neonatal period may be treated with surgery alone; however, those that occur after the neonatal period may be more likely to recur.
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Neoplasias Encefálicas/diagnóstico , Neoplasias Encefálicas/patología , Encéfalo/patología , Hemangiopericitoma/diagnóstico , Hemangiopericitoma/patología , Encéfalo/cirugía , Neoplasias Encefálicas/cirugía , Hemangiopericitoma/cirugía , Humanos , Lactante , Imagen por Resonancia Magnética , Masculino , Invasividad Neoplásica , Tomografía Computarizada por Rayos XRESUMEN
Tissue diagnosis is necessary for optimal treatment of pineal region tumors in children. Preoperative staging should include craniospinal MR imaging with and without gadolinium DTPA enhancement, CSF sampling for cytology, and measurement of biologic tumor markers in serum and CSF. Surgical approach is determined by results of preoperative MR imaging and the extent of resection by the results of staging and intraoperative frozen-section histopathologic evaluation. There is no longer a role for the radiation test dose (2000 cGy) in the management of these tumors. Postoperative treatment is based on histopathology and extent of disease. Benign tumors are treated with surgery only, and nondisseminating focal tumors with surgery and focal radiation therapy. Non-germinoma malignant germ cell tumors are best treated with neoadjuvant chemotherapy followed by radiation therapy given focally for focal disease; craniospinal radiation therapy is reserved for patients with evidence of disseminated disease at the completion of induction chemotherapy.
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Astrocitoma/cirugía , Neoplasias Encefálicas/cirugía , Glándula Pineal/cirugía , Pinealoma/cirugía , Astrocitoma/diagnóstico , Astrocitoma/patología , Biomarcadores de Tumor/análisis , Biopsia , Neoplasias Encefálicas/diagnóstico , Neoplasias Encefálicas/patología , Niño , Craneotomía , Humanos , Imagen por Resonancia Magnética , Glándula Pineal/patología , Pinealoma/diagnóstico , Pinealoma/patología , PronósticoRESUMEN
In castrated male goats, two flexible catheters, one open ended for reference and the other ending in a 1-mm-diam glass bulb pH electrode, were advanced ventrally through a left posterior fossa craniotomy into the subarachnoid space between the 9th and 10th cranial nerve roots, passing medially into cerebrospinal fluid (CSF) over the medullary ventral surface (MVS). They were anchored to dura and fascia, tunneled under the scalp, and terminated in connectors on the left horn. After several days for recovery, while the animals were awake, the effects of CO2 and hypoxia on pH of the film of CSF between the pia and arachnoid (pHMVS) were recorded along with end-tidal PCO2 and PO2 (mass spectrometer), ventilation (pneumotachometer) through a permanent tracheostomy, and, when possible, ear arterial O2 saturation (SaO2). High PCO2 acidified MVS as expected: delta pH MVS/delta log PCO2. = -0.64 +/- 0.14, producing a ventilatory response slope delta VI/delta pHMVS = 372 l/min. Hypoxia resulted in acid shifts even when PCO2 was allowed to fall. The development of hypoxic acidosis was related to the location of pH electrodes determined at necropsy. In isocapnic hypoxia, pH over putative chemoreceptor surfaces fell in proportion to desaturation: delta pHMVS = 0.0033(SaO2)-0.34, r = 0.80, Sy.x = 0.025. With uncontrolled arterial PCO2, similar acidosis occurred when SaO2 fell below 85-90%: delta pHMVS = 0.0039(SaO2)-0.34, r = 0.88, Sy.x = 0.032. With constant hypoxia, pH fell (tau = 3.7 +/- 2.2 min) to a plateau after 10-20 min and showed rapid recovery (tau = 2.0 +/- 1.3 min).(ABSTRACT TRUNCATED AT 250 WORDS)
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Acidosis/metabolismo , Hipoxia Encefálica/metabolismo , Bulbo Raquídeo/metabolismo , Acidosis/etiología , Animales , Células Quimiorreceptoras/efectos de los fármacos , Células Quimiorreceptoras/metabolismo , Doxapram/farmacología , Electrodos , Espacio Extracelular/metabolismo , Femenino , Cabras , Concentración de Iones de Hidrógeno , Hipoxia Encefálica/complicaciones , Cinética , Masculino , Puente/metabolismoRESUMEN
The incidence of primary central nervous system (CNS) lymphoma has increased rapidly in patients with acquired immunodeficiency syndrome (AIDS) and is predicted to exceed 1800 cases annually by 1991. To characterize the natural history and response to radiation therapy (RT) of these lesions, the authors have reviewed the clinical histories of 55 AIDS patients with biopsy-proven primary CNS lymphomas. The tumors responded both clinically and radiologically to whole-brain RT consisting of 4000 rad in 267-rad fractions over 3 weeks or an equivalent neuroret dose. The mean duration of survival from the appearance of symptoms consistent with the mass lesion was significantly greater in patients who received RT than in those who did not (42 vs. 134 days, p less than 0.5; median 27 vs. 119 days). Autopsy findings showed that patients who did not receive RT died from tumor progression, whereas those who completed RT died of opportunistic infections. Patients with AIDS who are suspected of having primary CNS lymphoma should therefore immediately undergo biopsy and, if the diagnosis is confirmed, whole-brain RT. With early diagnosis and treatment, these tumors respond to, and patients benefit from, RT. Survival of such patients may in future be prolonged by more effective treatments for systemic opportunistic infections.
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Síndrome de Inmunodeficiencia Adquirida/complicaciones , Neoplasias Encefálicas/radioterapia , Linfoma/radioterapia , Síndrome de Inmunodeficiencia Adquirida/mortalidad , Adulto , Neoplasias Encefálicas/diagnóstico por imagen , Neoplasias Encefálicas/patología , Neoplasias Encefálicas/cirugía , Humanos , Linfoma/diagnóstico por imagen , Linfoma/patología , Linfoma/cirugía , Tasa de Supervivencia , Tomografía Computarizada por Rayos XRESUMEN
We report a case of anaphylaxis caused by irrigation with a bacitracin solution during lumbar laminectomy. The patient had been exposed to bacitracin during a previous anterior cervical discectomy. We recommend avoiding the use of irrigation solutions containing bacitracin in patients with previous systemic exposure to this antibiotic.