RESUMEN
BACKGROUND: Single-session stereotactic radiosurgery (SRS) treatment of vestibular schwannomas results in excellent tumor control. It is not known whether functional outcomes can be improved by fractionating the treatment over multiple sessions. OBJECTIVE: To examine tumor control and complication rates after multisession SRS. METHODS: Three hundred eighty-three patients treated with SRS from 1999 to 2007 at Stanford University Medical Center were retrospectively reviewed. Ninety percent were treated with 18 Gy in 3 sessions, targeting a median tumor volume of 1.1 cm3 (range, 0.02-19.8 cm3). RESULTS: During a median follow-up duration of 3.6 years (range, 1-10 years), 10 tumors required additional treatment, resulting in 3- and 5-year Kaplan-Meier tumor control rates of 99% and 96%, respectively. Five-year tumor control rate was 98% for tumors < 3.4 cm3. Neurofibromatosis type 2-associated tumors were associated with worse tumor control (P = .02). Of the 200 evaluable patients with pre-SRS serviceable hearing (Gardner-Robertson grade 1 and 2), the crude rate of serviceable hearing preservation was 76%. Smaller tumor volume was associated with hearing preservation (P = .001). There was no case of post-SRS facial weakness. Eight patients (2%) developed trigeminal dysfunction, half of which was transient. CONCLUSION: Multisession SRS treatment of vestibular schwannomas results in an excellent rate of tumor control. The hearing, trigeminal nerve, and facial nerve function preservation rates reported here are promising.
Asunto(s)
Neuroma Acústico/cirugía , Radiocirugia/métodos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Femenino , Estudios de Seguimiento , Pérdida Auditiva/etiología , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Neurofibromatosis 2/etiología , Neuroma Acústico/mortalidad , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
INTRODUCTION: A myriad of geopolitical and financial obstacles have kept modern neurosurgery from effectively reaching the citizens of the developing world. Targeted neurosurgical outreach by academic neurosurgeons to equip neurosurgical operating theaters and train local neurosurgeons is one method to efficiently and cost effectively improve sustainable care provided by international charity hospitals. The International Neurosurgical Children's Association (INCA) effectively improved the available neurosurgical care in the Maria Auxiliadora Hospital of Lima, Peru through the advancement of local specialist education and training. METHODS: Neurosurgical equipment and training were provided for the local neurosurgeons by a mission team from the University of California at San Diego. RESULTS: At the end of 3 years, with one intensive week trip per year, the host neurosurgeons were proficiently and independently applying microsurgical techniques to previously performed operations, and performing newly learned operations such as neuroendoscopy and minimally invasive neurosurgery. CONCLUSION: Our experiences may serve as a successful template for the execution of other small scale, sustainable neurosurgery missions worldwide.
Asunto(s)
Relaciones Comunidad-Institución , Países en Desarrollo , Neurocirugia/educación , Organizaciones de Beneficencia , Hospitales , Humanos , Neurocirugia/instrumentación , Perú , Recursos HumanosRESUMEN
Chordomas are malignant neoplasms that typically arise in the axial spine and primarily affect adults. When chordomas arise in pediatric patients they are more likely to display unusual histological features and aggressive behavior. We noted the absence of SMARCB1/INI1 expression by immunohistochemistry in an index case of poorly differentiated chordoma of the sacrum, leading us to further examine SMARCB1/INI1 expression as well as that of brachyury, a highly specific marker of notochordal differentiation, in 3 additional poorly differentiated chordomas of the clivus, 10 typical chordomas, and 8 atypical teratoid/rhabdoid tumors (AT/RTs). All 4 poorly differentiated chordomas and all AT/RTs lacked nuclear expression of SMARCB1/INI1, while the 10 typical chordomas maintained strong nuclear SMARCB1/INI1 immunoreactivity. All 10 typical and 4 poorly differentiated chordomas expressed brachyury; all 8 AT/RTs were brachyury immunonegative. Cytogenetic evaluation utilizing FISH probes near the SMARCB1/INI1 locus on chromosome 22q was also performed in all of the poorly differentiated chordomas in this series. Three of the four poorly differentiated chordomas had evidence for deletion of this region by FISH. Analysis of the SMARCB1/INI1 gene sequence was performed using formalin-fixed paraffin-embedded tissue in all cases and no point mutations were observed. In summary, all poorly differentiated chordomas in this series showed the absence of SMARCB1/INI1 expression, and were reliably distinguished from AT/RTs, clinically by their characteristic primary sites of origin and pathologically by strong nuclear brachyury expression. Our findings reveal a likely role for SMARCB1/INI1 in a subset of chordomas with aggressive features.
Asunto(s)
Cordoma/genética , Cordoma/patología , Proteínas Cromosómicas no Histona/antagonistas & inhibidores , Proteínas Cromosómicas no Histona/biosíntesis , Proteínas de Unión al ADN/antagonistas & inhibidores , Proteínas de Unión al ADN/biosíntesis , Eliminación de Gen , Mutación/genética , Neoplasias de la Columna Vertebral/genética , Neoplasias de la Columna Vertebral/patología , Factores de Transcripción/antagonistas & inhibidores , Factores de Transcripción/biosíntesis , Diferenciación Celular/genética , Niño , Preescolar , Cordoma/metabolismo , Proteínas Cromosómicas no Histona/genética , Proteínas de Unión al ADN/genética , Femenino , Humanos , Lactante , Masculino , Invasividad Neoplásica/genética , Invasividad Neoplásica/patología , Proteína SMARCB1 , Neoplasias de la Columna Vertebral/metabolismo , Factores de Transcripción/genéticaRESUMEN
In contrast to sagittal craniosynostosis, the role of endoscopic, minimally invasive approaches in the treatment of metopic craniosynostosis with resulting trigonocephaly is not as well defined. We reviewed the senior authors' (H.M. and S.C.) clinical experience in the treatment of children with metopic craniosynostosis using a variety of endoscopic and open techniques. Thirty-three patients were treated at a single institution during a 5-year period with between 3 and 8 years of follow-up. Sixteen patients underwent 3 variations of endoscopic approaches, and 17 patients had open fronto-orbital advancement. Clinical parameters of the 2 groups were examined including age at surgery, blood loss, operative time, transfusion volume, hospital stay, complications, use of postoperative cranial banding, and the need for reoperation for persistent deformity. The various endoscopic and open techniques used by the authors in the treatment of metopic craniosynostosis are discussed in detail, including rational for individual technique selection and preliminary impressions regarding clinical outcome.
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Suturas Craneales/anomalías , Craneosinostosis/cirugía , Endoscopía/métodos , Hueso Frontal/anomalías , Procedimientos de Cirugía Plástica/métodos , Factores de Edad , Pérdida de Sangre Quirúrgica , Transfusión Sanguínea , Preescolar , Suturas Craneales/cirugía , Femenino , Estudios de Seguimiento , Hueso Frontal/cirugía , Dispositivos de Protección de la Cabeza , Hospitalización , Humanos , Lactante , Tiempo de Internación , Masculino , Procedimientos Quirúrgicos Mínimamente Invasivos , Órbita/cirugía , Aparatos Ortopédicos , Osteotomía/métodos , Planificación de Atención al Paciente , Complicaciones Posoperatorias , Recurrencia , Reoperación , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
Among the relatively few surgeons to be awarded the Nobel Prize was Alexis Carrel, a French surgeon and pioneer in revascularization surgery at the turn of the 20th century. The authors trace the humble beginnings of cerebral revascularization surgery through to the major developments that helped shape the modern practice of cerebral bypass surgery. They discuss the cornerstone studies in the development of this technique, including the Extracranial/Intracranial Bypass Study initiated in 1977. Recent innovations, including modern techniques to monitor cerebral blood flow, microanastomosis techniques, and ongoing trials that play an important role in the evolution of this field are also evaluated.
Asunto(s)
Revascularización Cerebral/historia , Revascularización Cerebral/métodos , Trastornos Cerebrovasculares/cirugía , Procedimientos Neuroquirúrgicos/historia , Procedimientos Neuroquirúrgicos/métodos , Animales , Arterias Cerebrales/patología , Arterias Cerebrales/fisiopatología , Arterias Cerebrales/cirugía , Trastornos Cerebrovasculares/patología , Trastornos Cerebrovasculares/fisiopatología , Ensayos Clínicos como Asunto/estadística & datos numéricos , Modelos Animales de Enfermedad , Historia del Siglo XIX , Historia del Siglo XX , Historia del Siglo XXI , Humanos , Microcirugia/métodos , Microcirugia/tendencias , Monitoreo Fisiológico/métodos , Monitoreo Fisiológico/tendencias , Procedimientos Quirúrgicos Vasculares/instrumentación , Procedimientos Quirúrgicos Vasculares/métodosRESUMEN
OBJECTIVE: We present a unique case of a recurrent osteoma within a cranioplasty performed with calcium phosphate bone cement. CLINICAL PRESENTATION: The patient is a 7-year-old boy who had initially undergone a craniotomy for resection of a frontal cranial tumor followed by a cranioplasty with artificial bone matrix. On routine follow-up evaluation 2 years later, the patient had a mass expanding from the cranioplasty. INTERVENTION: At the time of reoperation, the patient was found to have a histopathologically confirmed recurrent osteoma within the artificial bone matrix. The patient later underwent repair of the frontal cranial defect using a patient-specific implant. CONCLUSION: We discuss this unusual case, treatment, and possible causes. We believe that a safety margin and curettage of the resection border as well as resection of the overlying periosteum might prevent recurrence.
Asunto(s)
Neoplasias Óseas , Fosfatos de Calcio/efectos adversos , Metilmetacrilato/efectos adversos , Osteoma , Cementos para Huesos/uso terapéutico , Neoplasias Óseas/diagnóstico , Neoplasias Óseas/etiología , Neoplasias Óseas/cirugía , Fosfatos de Calcio/uso terapéutico , Niño , Humanos , Masculino , Recurrencia Local de Neoplasia/diagnóstico por imagen , Recurrencia Local de Neoplasia/cirugía , Osteoma/diagnóstico , Osteoma/etiología , Osteoma/cirugía , Radiografía , Tomógrafos Computarizados por Rayos XRESUMEN
The hormonal and hemodynamic effects of pregnancy accelerate the growth of hemangioblastomas in Von Hippel-Lindau syndrome (VHL), leading to increased symptoms and risk to both the mother and fetus. A review of the literature on the treatment of VHL in pregnancy would suggest surgical intervention should be considered with worsening clinical status. Introducing this review is a description of our patient with VHL, who uniquely presented in pregnancy with a cervical hemangioblastoma.
Asunto(s)
Enfermedad de von Hippel-Lindau/complicaciones , Enfermedad de von Hippel-Lindau/patología , Femenino , Hemangioblastoma/complicaciones , Hemangioblastoma/patología , Humanos , Imagen por Resonancia Magnética , Embarazo , Mujeres Embarazadas , Neoplasias de la Columna Vertebral/complicaciones , Neoplasias de la Columna Vertebral/patología , Adulto Joven , Enfermedad de von Hippel-Lindau/etiología , Enfermedad de von Hippel-Lindau/terapiaRESUMEN
BACKGROUND: Vertebral compression fractures represent a serious health care problem. Vertebroplasty and kyphoplasty have been gaining popularity in the treatment of symptomatic compression fractures that are often secondary to osteoporosis or neoplasia. METHODS: We use the NIS database from 1993 through 2004 to examine trends in VCFs. Patients with VCFs were identified using primary diagnostic codes (ICD-9-pathologic vertebral fracture, 733.13) and cross-referenced with ICD-9 procedure codes (ICD-9-VAPs, 78.49; kyphoplasty, 81.66; and vertebroplasty, 81.65). RESULTS: In 2004, more than 23 000 VAPs were performed nationwide on an inpatient basis for VCFs. This represented a 12 900% increase in the number of procedures performed since 1993. Approximately 60% of patients were female and aged 65 to 84 years. Nearly 60% of vertebroplasties and 25% of kyphoplasties were on patients admitted from the ED. Large-sized hospitals and those hospitals located in the southern United States accounted for most of the cases. The mean LOS was 3.7 days for kyphoplasty and 7.3 days for vertebroplasty. The final discharge disposition, home vs institution (nursing home, rehabilitation), was 50:50 for vertebroplasty and 77:23 for kyphoplasty. The mean hospital charges for both procedures were comparable, and the total "national bill" was approximately $672 million in 2004. CONCLUSIONS: With the continued aging of the population, VCFs represent an increasingly important health care issue. The staggering increase in the number of minimally invasive VAPs performed illustrates the continued adoption of these innovative technologies and early trends in their applications.
Asunto(s)
Fracturas por Compresión/cirugía , Fracturas de la Columna Vertebral/cirugía , Columna Vertebral/cirugía , Vertebroplastia/estadística & datos numéricos , Vertebroplastia/tendencias , Adolescente , Adulto , Distribución por Edad , Factores de Edad , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Femenino , Control de Formularios y Registros , Costos de la Atención en Salud/estadística & datos numéricos , Hospitales/estadística & datos numéricos , Hospitales/tendencias , Humanos , Tiempo de Internación , Cuidados a Largo Plazo/estadística & datos numéricos , Cuidados a Largo Plazo/tendencias , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/economía , Procedimientos Quirúrgicos Mínimamente Invasivos/estadística & datos numéricos , Procedimientos Quirúrgicos Mínimamente Invasivos/tendencias , Distribución por Sexo , Fracturas de la Columna Vertebral/patología , Fracturas de la Columna Vertebral/fisiopatología , Columna Vertebral/patología , Columna Vertebral/fisiopatología , Estados Unidos , Vertebroplastia/economía , Adulto JovenRESUMEN
OBJECTIVE: The cerebellopontine angle (CPA) is a rare location for an arachnoid cyst. We describe a patient with a CPA arachnoid cyst who presented with hoarseness (unilateral vocal cord paralysis) and dysphagia secondary to isolated compression of the vagus nerve. This rare presentation of a CPA arachnoid cyst has not been reported previously. CLINICAL PRESENTATION: The patient described is a 50-year-old man who experienced a precipitous onset of hoarseness and dsyphagia. An otolaryngological evaluation revealed right-sided vocal cord paralysis. Brain magnetic resonance images displayed a cystic mass at the right CPA and anterior displacement of the vagus nerve. INTERVENTION: The patient underwent retrosigmoidal craniectomy with cyst fenestration, which was well tolerated. Intraoperatively, Cranial Nerve X was found splayed over the cyst and was consequently decompressed. CONCLUSION: Postoperatively, the patient's dysphagia completely resolved. However, the results of a laryngeal electromyocardiogram revealed minimal evidence of recovery in the affected vocal fold, and the patient continued to suffer from dysphonia. Although CPA arachnoid cysts are rare, they should be considered when a patient presents with an isolated cranial nerve palsy. Treatment options include cyst fenestration and cranial nerve decompression.