Biomedical subjects
Publications and source records attributed to N Kitchen.
Seizures as a presenting feature of unruptured cerebral aneurysm are unusual. We report two cases of unruptured cerebral aneurysm presented with seizures. In both cases the seizures controlled following surgical ablation of the aneurysm.
OBJECTIVES: To characterise the clinical features and response to treatment of supratentorial cavernomas associated with epilepsy. METHODS: A systematic review of the literature was carried out and a retrospective case series of patients with cavernoma diagnosed by MRI and/or histology was compiled. Patient selection biases in the literature review were reduced as far as possible by selection of unbiased publications. RESULTS: In the literature, cavernomas were relatively less common in the frontal lobes. There were multiple cavernomas in 23% of cases. The main clinical manifestations were seizures (79%) and haemorrhage (16%). The annual haemorrhage rate was 0.7%. The outcome after excision was good with improvement in seizures in 92% of patients. In the case series the surgical outcome was less favourable, reflecting inclusion of a higher proportion of patients with intractable epilepsy. In both the literature review and the case series, outcome was poorer in cases with a longer duration of seizures at the time of surgery. CONCLUSIONS: The good surgical results, particularly in cases treated earlier, and the significant cumulative haemorrhage rate, suggest that excision is the optimum treatment. However, these factors have not been examined prospectively and, despite the availability of several retrospective studies, the optimum treatment, particularly for non-intractable cases, will only be determined by a prospective study.
Accurate localization of lesions and minimization of trauma to the surrounding brain are of paramount importance in intracranial surgery. Stereotactic frame systems provide highly accurate methods of localization, which has been further enhanced by the introduction of sophisticated imaging modalities, and recently by the development of interactive image-guided neurosurgical technology.
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Operative neurosurgery has recently entered an exciting era of image guided surgery or neuronavigation and application of this novel technology is beginning to have a significant impact in many ways in a variety of intracranial procedures. In order to fully assess the advantages of image guided techniques over conventional planning and surgery in selected cases, detailed prospective evaluation has been carried out during the advanced development of an optically tracked neuronavigation system. Over a 2-year period, 300 operative neurosurgical procedures have been performed with the assistance of interactive image guidance, as well as the development of new software applications and hardware tools. A broad range of intracranial neurosurgical procedures were seen to benefit from image guidance, including 163 craniotomies, 53 interactive stereotactic biopsies, 7 tracked neuroendoscopies and 37 complex skull base procedures. The most common pathological diagnoses were cerebral glioma in 98 cases, meningioma in 64 and metastasis in 23. Detailed analysis of a battery of postoperative questions revealed benefits in operative planning, appreciation of anatomy, lesion location, safety of surgery and greatly enhanced surgical confidence. The authors believe that image guided surgical technology, with new developments such as those described, has a significant role to play in contemporary neurosurgery and its widespread adoption in practice will be realised in the near future.
OBJECTIVE AND IMPORTANCE: We report a case of a neurenteric cyst of the cerebellopontine angle and review the five previously reported cases. The pathology and classification of these cysts are discussed. CLINICAL PRESENTATION: The patient presented with a 1-month history of nausea, vomiting, vertigo, and sudden hearing loss. INTERVENTION: The cyst was decompressed by a retrosigmoid approach. After recurrence of symptoms at 2 months, further decompression was required. CONCLUSION: The patient achieved a good outcome after the second operation, with cessation of her vomiting and vertigo, although she had residual hearing loss. Four of the five previously reported patients experienced satisfactory outcomes after surgery. The definitive diagnosis of these rare lesions is made using immunocytochemical techniques.
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We performed conventional T2-weighted brain MRI examinations in six patients with multiple sclerosis (MS) and trigeminal neuralgia. In all patients brainstem lesions in positions expected to involve trigeminal fibers, particularly the entry zone of sensory fibers, were demonstrated. Compression of the trigeminal nerve by ectatic vessels, a recognized cause of idiopathic trigeminal neuralgia, was not observed. We conclude that in MS trigeminal neuralgia is usually caused by demyelinating lesions affecting pontine trigeminal pathways.
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The incidence of postdural puncture headache (PDPH) was studied in in-patients after spinal anaesthesia with 25 gauge Polymedic needle (Sprotte-like), for lower segment caesarean section (LSCS). A total of 281 women who underwent LSCS were studied, at the maternity unit of St. Peter's Hospital, Chertsey, Surrey, U.K. Of these, 125 women had a spinal, 93 general and 63 epidural anaesthesia. All the women were questioned about the presence of headache between the second and fourth post-operative day. Its severity was assessed with a visual analogue scale. Women who had an epidural or a general anaesthesia were used as controls. Out of 281 women studied, none complained of PDPH. Four women in the spinal anaesthetic group, complained of headache which did not have the characteristics of PDPH. The 25 gauge Polymedic spinal needle appears to be safe and satisfactory for performing spinal anaesthesia for LSCS.
1. The majority of the published literature on the radiotherapeutic treatment of epilepsy suffers because it has involved neither radiotherapists nor epileptologists. 2. Papers have either been written describing an incidental beneficial effect (these suffer from being retrospective analyses) or by enthusiasts (where one must question patient selection). In addition there are a small number of very detailed and useful individual case reports. 3. Despite the reservations it would appear that radiation can have beneficial effects on seizures, and this effect has been described for a wide variety of conditions using a wide variety of treatment modalities. 4. There are grounds for prospective clinical trials to test the putative therapeutic efficacy of cerebral irradiation. However, it is essential that these are carried out by a group involving an established epilepsy surgery programme and a radiotherapy department conversant with the complex issues involved in focussed radiation treatment.
Neurosurgical practice in the treatment of affective disorders has changed dramatically over the last 40 years. This paper traces the changes which have occurred in one institution, namely Atkinson Morley's Hospital, Wimbledon, London, UK from 1948 to the present day. Freehand operations designed by McKissock and performed on large numbers of patients disappeared as better non-surgical treatments became available and long term complications and treatment failures became dearer. In the 1970's stereotactic limbic leucotomy, a much more focal and accurate operation, was devised and became popular. The present day practice utilises precisely the same techniques as the original stereotactic limbic leucotomy but is employed on small numbers of patients. The procedure continues to have a role for those few patients with severe psychiatric illness, particularly obsessive compulsive disorder, which has proved refractory to other therapeutic modalities.
Patients treated by a single neurosurgeon over a period of 17 years have been reviewed in order to assess the volume and nature of neurosurgical work performed on patients aged over 65 years. Based on this data we report: (1) The age distribution of the principal neurosurgical conditions, drawing attention to those conditions which are over- and under-represented in elderly patients. (2) A steady increase in the number of patients over 65 admitted over the last 15 years. (3) The numbers and types of neurosurgical operations carried out on elderly patients at the present time compared with 10 years ago. (4) The outcome of first-time surgery for intracranial meningiomas in 144 patients analysed by age. It is clear that a large and increasing proportion of neurosurgical work is carried out on persons over the age of 65. Age by itself appears to be no bar to a good outcome after a major neurosurgical operation provided that the surgery is elective and is not accompanied by a diffuse neurological disturbance.
A patient with a traumatic occult spinal pseudomeningocele is presented. The possible etiology and the use of a lumboperitoneal shunt in this situation are discussed.
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