Complex penetrating cranial base trauma: case report demonstrating multidisciplinary management.
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Adolescent↗
Biomedical subjects
T C Origitano
Publications and source records attributed to T C Origitano.
Joint ventures at the skull base. Defining the roles of the neurosurgeon and non-neurosurgeon.
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Humans↗
Selecting aneurysms for adequate exposure without extended cranial base approaches: neurovascular decision-making counterpoint.
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Decision Making↗
Optimal clip application and intraoperative angiography for intracranial aneurysms.
BACKGROUND: The actual incidence of residual aneurysm after clipping is unknown. The natural history of residual aneurysm can be regrowth and hemorrhage. Intraoperative angiography offers a cost-effective, safe interdiction to the problem of residual aneurysm and parent vessel stenosis. METHODS/RESULTS: Forty consecutive patients harboring 54 aneurysms underwent 42 operative procedures to clip 52 aneurysms, during which 220 intraoperative angiographic runs were performed. Ninety-three percent of the procedures were performed on patients with acute subarachnoid hemorrhage. There were 4 giant (>2.5 cm, 4/52 = 8%, all anterior circulation), 21 large (1.0-2.5 cm, 21/52 = 40%, 16/ 21 = 76% anterior circulation, 6/21 = 28% posterior circulation), and 27 small (<1.0 cm, 27/52-52%, 22/27 = 81% anterior circulation, 5/27 = 18% posterior circulation) aneurysms. Intraoperative angiography led to clip adjustment in 18/52 = 34% of aneurysms (4/18 = 22% for parent artery stenosis, 8/18 = 44% for residual aneurysm and 6/18 = 33% for both). Of the 18 adjustments made, 16 = 88% were made on giant or large aneurysms and two were small (one was a complex anterior communicating and one was a vertebral junction aneurysm). Follow-up angiography was performed on 26/42 = 62% of operative cases. Postoperative angiography confirmed intraoperative angiography in all cases. Two complications occurred during 220 angiographic runs: one embolic stroke and one incident of equipment failure. CONCLUSION: A grading scale was applied to test the relationship between anatomical site and size as they relate to the necessity for clip adjustment for complete aneurysm obliteration and/or parent artery compromise. Significance was related to site (basilar bifurcation, anterior communicating, middle cerebral bifurcation, and ophthalmic) and size (>1.0 cm), both as independent and codependent variables. An analysis of the cost-effectiveness of intraoperative angiography was demonstrated.
Adult↗
PLA2 activity regulates Ca2+ storage-dependent cellular proliferation.
The objective of this study is to determine the role of arachidonic acid (AA) in cell proliferation by inhibiting AA synthetic enzyme phospholipase A2 (PLA2) and to determine its involvement in the role of the second messenger intracellular calcium (Ca2+). Methods used to determine the effects on proliferation of cell cultures of primary meningioma and astrocytoma U373-MG included treatment with micromolar concentrations of PLA2 inhibitors 4-bromophenacylbromide and quinacrine. Effects of these drugs on proliferation were further investigated by the application of concentrations that inhibit growth by 50% while antagonizing these agents with AA replacement. Free cytosolic Ca2+ was measured with the use of fluorescent dye Fura-2 during PLA2 agonist/antagonist studies. These Ca2+ measurements were performed in the absence of extracellular Ca2+ to identify the contribution of intracellular Ca2+ sources. PLA2 inhibition resulted in decreased growth of cultured astrocytoma and meningioma cells in a dose-dependent manner in the micromolar range. This inhibitory effect was antagonized by the addition of AA. PLA2 inhibition caused an elevation of basal-cytosolic-free [Ca2+] while depleting internal Ca2+ stores. These Ca2+ changes were also antagonized by the addition of AA. In conclusion, these results demonstrate that AA, a PLA2 enzyme product, is involved in regulating the growth rate of these cell types. The PLA2 pathway also regulates the maintenance of the internal Ca2+ stores. Ca2+ is known to be a growth-related intracellular second messenger. These results suggest that the growth regulatory functions of AA are mediated by Ca2+-dependent mechanisms.
Astrocytoma↗
Familial cervical spondylosis. Case report.
Cervical spondylosis is a disease that is often attributed to aging and considered the result of degenerative changes in the spine. The idea that there is a genetic predisposition to develop diseases of the skeletal elements of the spine has been discussed previously, but has never been proven conclusively. The authors report three cases of severe cervical spondylosis in patients who are first-degree relatives: a mother and her two sons. All three individuals had cervical disc herniations and stenosis at C3-4, C4-5, C5-6, and C6-7, and all three required decompressive procedures. The location and degree of cervical spondylosis were as similar among these three patients as they have been in identical twins reported in other studies. Such familial inheritance of cervical spondylosis has been reported only once. The existence of familial cervical spondylosis is not an unrealistic proposal because other studies have shown that genetics determines the shape of one's spine and that similar spines tend to degenerate in similar ways. Therefore, genetic counseling for a family such as the one reported here may prove to be of great benefit to warn siblings that they are at high risk for cervical spine injury. However rare it might be, familial cervical spondylosis may be a phenomenon that any spine surgeon should suspect in a family with cervical spine abnormalities found in several members.
Adult↗
Venous drainage of the inferolateral temporal lobe in relationship to transtemporal/transtentorial approaches to the cranial base.
OBJECTIVE: Intimate to the application of lateral transtemporal approaches to the cranial base are the identification, manipulation, and/or the sacrifice of the venous anatomy of the inferolateral temporal lobe and the superior petrosal sinus and the transection of the tentorium. This study demonstrates the relationship and variability of the venous drainage of the lateral and inferior surfaces of the temporal lobe. METHODS: Twenty-one specially prepared, injected cadaver specimens yielded 40 temporal lobes for examination. The venous systems in these specimens were traced from their origins on the temporal lobe (venous drainage complexes) to the transverse/petrosal sinuses, and the geometry of these venous complexes (venous configuration) was noted. The measurements of each complex's entry to the sinuses were noted. RESULTS: Four distinct venous drainage complexes were identified: 1) the lateral complex, 2) the anteroinferior complex, 3) the medial-inferior complex, and 4) the posteroinferior complex. Three basic venous configurations were found: 1) the candelabra of veins uniting to form one large draining vein, 2) multiple independent draining veins, and 3) venous lakes running in the tentorium before entering the sinuses. The lateral complex, incorporating the classic "vein of Labbé," was present in 100% of the specimens. However, in the majority of cases, it did not represent the dominant venous drainage of the lateral and inferior surfaces of the temporal lobe. CONCLUSION: An understanding of the complexity and diversity of the venous drainage complexes and their configurations is necessary to avoid venous complications during lateral cranial base surgery.
Cerebral Veins↗
Lazaroids inhibit proliferation of cultured human astrocytoma cells.
Lazaroids (or 21-aminosteroids) are potent lipid peroxidation inhibitors and are more potent antioxidants than steroids which have been shown to suppress tumor proliferation. The effects of two lazaroid compounds (U-75389G and U-83836E) were tested on the proliferation of a human brain astrocytoma cell line U-373MG. Both lazaroids had dose-dependent growth-inhibitory effects on the proliferation of U-373MG. For purposes of comparison, two steroids (methylprednisolone and dexamethasone) and a highly potent antioxidant (alpha-tocopherol) were tested under similar experimental conditions and were found to have antiproliferative effects as well, although at higher dose ranges. As cell growth-inhibitors, lazaroids are more effective than alpha-tocopherol while they are advantageous over glucocorticoids for their actions are devoid of the usual glucocorticoid side-effects.
Antineoplastic Agents↗
The need for neurological surgery programs to be departments.
The Decade of the Brain has brought recognition of the contributions neurological surgery has made to modern medicine, and neurological surgery training programs are a cornerstone of these achievements. While neurosurgeons are celebrating their achievements, however, a number of social, political, and administrative issues threaten to undermine the future of these programs. We discuss the ramifications of departmental status to the future of neurological surgery. These include the implications for operative experience-for example, carotid endarterectomy, spine instrumentation, acoustic tumors-the economic impact of a department versus a division, the ability to direct research, administrative input at the institutional level, and self-determination. We discuss the requirements for programmatic change and recommendations for national support.
Education, Medical↗
CT angiographic-guided frameless stereotactic-assisted clipping of a distal posterior inferior cerebellar artery aneurysm: technical case report.
BACKGROUND: The development of frameless stereotaxis allows for repetitive intraoperative localization with millimeter accuracy. High-resolution computed tomographic (CT) angiography provides multiplanar, three-dimensional imaging of cerebral vascular lesions. The image data set generated during CT angiography can be used for localization in frameless stereotaxis when performed with appropriate fiducials in place. METHODS: The feasibility of melding these two technologies was tested on a patient with a small (5 mm), distal ruptured posterior inferior cerebellar artery aneurysm, which was visualized by CT angiography and localized by frameless stereotaxis. RESULTS: Visualization by CT angiography and intraoperative localization by frameless stereotaxis were successful. CONCLUSIONS: The practical application of this technology meld is demonstrated in this sample case. Applications to distal anterior cerebral artery aneurysms, abnormal flow-related aneurysms associated with arteriovenous malformations, and mycotic aneurysms are discussed.
Angiography↗
Endoscopic closure of postsurgical anterior cranial fossa cerebrospinal fluid leaks.
OBJECTIVE: The primary objective of this study is to present an alternative technique to closure of anterior cranial fossa cerebrospinal fluid (CSF) leaks. This study also serves to review our experience with our technique and presents some technical "tricks" we have learned through experience. METHODS: The design of this study is a clinical chart review. The setting is an academic medical center. RESULTS: Eight patients were referred for closure of postsurgical CSF leaks. Seven of eight patients underwent closure with one attempt and closure was achieved after a second attempt in one patient. Follow-up ranged from 1.5 to 4.0 years. There were no complications. No patient developed an acute or delayed episode of meningitis. CONCLUSION: The technique of endoscopic closure of a CSF leak is a safe and effective means for closure of a postsurgical anterior cranial fossa CSF fistula when performed by an experienced operator.
Adenoma↗
Vasospasm after resection of skull base tumors.
Vasospasm after resection of skull base tumors is a rare complication that often produces serious ischemic sequelae. In four of the authors' recent cases, vasospasm complicated the patient's postoperative course. A review of the literature produced a number of cases that can help determine possible causes of vasospasm after tumor resection, ways to prevent it, and methods to evaluate it when it occurs. The cause appears to be multifactorial and the surgical approach may contribute to the pathogenesis of vasospasm. Physicians must have a high degree of suspicion to detect vasospasm at an early stage of skull base surgery. Cerebral blood flow measurement and transcranial Doppler are useful monitoring tools.
Adenocarcinoma↗
In vitro growth inhibition of growth factor-stimulated meningioma cells by calcium channel antagonists.
Studies have shown that a majority of meningiomas contain receptors for platelet-derived growth factor and epidermal growth factor and that these growth factors promote the proliferation of meningioma cells in culture. Although the mechanism of action has not been elucidated, intracellular calcium appears to be part of the signal transduction mechanism. Because alterations in intracellular calcium could interrupt this pathway and decrease cellular proliferation, we investigated the effects of calcium channel-blocking agents on the growth of meningioma cells in vitro. Primary meningioma cell cultures were established, and the cells were characterized by light and electron microscopy and by immunohistochemical studies. Then, the cultures were given growth factors and/or various calcium channel antagonists, and growth rates were measured. A dose-response decrease in cell growth was seen when verapamil, nifedipine, or diltiazem (voltage-dependent calcium channel-blocking agents) was added to serum-containing media. Also, these drugs blocked the growth stimulation of epidermal growth factor and platelet-derived growth factor in a similar fashion. Dantrolene, which inhibits the release of sequestered intracellular calcium, was also an effective blocker of the mitogenic stimulation of these growth factors.
Adult↗
Inhibition of in vitro meningioma proliferation after growth factor stimulation by calcium channel antagonists: Part II--Additional growth factors, growth factor receptor immunohistochemistry, and intracellular calcium measurements.
We have previously reported that calcium channel antagonists can block both the growth of meningiomas in culture and the potent growth stimulation of meningioma cells by epidermal growth factor (EGF) and platelet-derived growth factor (PDGF). This study further defines the nature of this growth inhibition. Primary meningioma cultures were established, and cells were characterized. Fibroblast growth factor or insulin-like growth factor-I growth stimulation in the presence of calcium channel antagonists was examined. In addition, the effects of ethylene glycol-bis-(aminoethylether) N,N,N',N"-tetraacetic acid and Bay K 8644, a calcium channel agonist, on the growth factors were analyzed. Growth factor receptor immunohistochemistry was performed on the original tumors and the in vitro meningioma cells. Twelve of 17 (71%) meningiomas in this study were positive for the EGF receptor, and 14 of 17 (82%) were positive for the PDGF receptor. Five of six (83%) of the culture cells were positive for the EGF receptor, and four of five (80%) were positive for the PDGF receptor. Intracellular calcium changes were quantified using the intracellular calcium-chelating, fluorescent dye, Fura-2. The growth stimulation of fibroblast growth factor and insulin-like growth factor-I on meningioma cells in culture was decreased in a dose-dependent manner by calcium channel antagonists. The growth stimulation of fibroblast growth factor and insulin-like growth factor-I was not affected by a reduction of extracellular calcium, whereas the growth stimulation of EGF and PDGF was. Interestingly, intracellular calcium was not increased after exposure to growth factors but was increased after serum stimulation. This increase could be blocked by preincubation with verapamil. Calcium channel antagonists can inhibit proliferation of meningioma cells in culture after stimulation with a number of growth factors. These drugs might disrupt intracellular calcium homeostasis or interfere with key elements of the growth factor signal transduction pathways. These mechanisms as well as the potential clinical relevance of these findings are discussed.
Adult↗
Vascular considerations and complications in cranial base surgery.
The technical evolution of cranial base surgery has resulted in approaches that allow more radical surgical extirpation of complex cranial base lesions. Our service has extensively applied these cranial base approaches for lesions of the cranial base. A subgroup of 100 patients who had cranial base tumors involving potential manipulation or sacrifice of carotid arteries underwent 20-minute balloon test occlusions coordinated with vascular assessments consisting of a combination of the following: 1) four-vessel cerebral angiogram with compression studies; 2) occlusion transcranial Doppler ultrasonography; 3) occlusion single-photon emission computed tomography perfusion studies; and 4) xenon-133 cerebral blood flow studies. Transient neurological deficits associated with balloon test occlusion occurred in 7 of 100 patients (7%). Subsequently, 18 patients underwent permanent carotid occlusion by endovascular detachable balloons. Delayed ischemic complications (> 72 h) occurred in 4 of 18 (22%) patients. Additionally, a number of vascular complications not predicted by the balloon occlusion tests and vascular assessments were experienced. Repeat vascular assessments defined the causes and guided treatment of ischemic patients. Ischemic complications were caused by hemodynamic insufficiency, embolization, vasospasm, radiation vasculopathy, and venous anomaly. Our experience leads us to believe that no vascular assessment exists today that can predict the occurrence of vascular complications accurately. The current enthusiasm for cranial base surgery must be tempered with the sober reality that management of cerebrovascular anatomy and physiology remain significant limitations. Consideration of potential cerebrovascular complications is paramount to successful outcome and implementation of cranial base surgery.
Adult↗
Skull base approaches to complex cerebral aneurysms.
The authors used skull base approaches to improve the surgical treatment of cerebral aneurysms. These approaches facilitate aneurysm surgery by allowing early proximal and distal vascular control, shortening and widening of the operative field, increasing the range of the surgeon's operative view and motion, and alleviating brain retraction. Twenty-two patients with ruptured giant or complex aneurysms were operated upon acutely using skull base approaches appropriate for their location: (1) the orbitocranial approach for anterior circulation, ophthalmic artery, and intracavernous lesions (n = 10); (2) the orbitozygomatic approach for aneurysms of the upper third of the basilar artery (n = 6); (3) the petrosal approach for aneurysms of the middle third of the basilar artery (n = 2); and (4) the far lateral-transcondylar approach for vertebrobasilar aneurysms (n = 4). Clipping and dissection of the aneurysms was facilitated by the skull base approaches. No surgical mortality occurred in this series of patients; transient cranial nerve paresis was the only morbidity related to the approaches. We compare the three-dimensional spatial geometry of skull base and conventional approaches, and discuss the advantages and nuances of skull base approaches.
Adult↗
Use of vascularized fat from the rectus abdominis myocutaneous free flap territory to seal the dura of basicranial tumor resections.
Resection of large skull base tumors may sometimes result in extirpation defects that are not amenable to local tissue closure. Patients with these tumors require free tissue transfer for closure of the intracranial space after basicranial tumor extirpation. The deep inferior epigastric artery supplies the rectus abdominis muscle and the skin and subcutaneous tissue of the lower abdomen. The closure of massive, central defects can be performed with a free flap designed from the ample rectus abdominis vascular territory. This free tissue donor site has abundant and reliable well-vascularized skin and subcutaneous tissue that can be customized to seal these tenuous areas and provide three-dimensional reconstruction. We have modified the rectus abdominis myocutaneous free flap in seven patients for reconstruction of the skull base. The subcutaneous fat was sculptured to form a soft, vascularized "cork" and was used for obliteration of the irregular deep portions of defects at the midcranial base against the repaired or unrepaired dura. All patients who had the vascularized fat used to obliterate the deep space had successful closure of the defect without cerebral spinal fluid leak. There were two wound infections and one donor-site hernia in this group. The judicious use of the vascular territory of the deep inferior epigastric vessels can accomplish secure three-dimensional reconstruction of the skull base. The flap can be reliably transferred, and the vascularized subcutaneous fat can be used to sequester and seal the dura repair.(ABSTRACT TRUNCATED AT 250 WORDS)
Adenocarcinoma↗
Photodynamic therapy for intracranial neoplasms: investigations of photosensitizer uptake and distribution using indium-111 Photofrin-II single photon emission computed tomography scans in humans with intracranial neoplasms.
Photodynamic therapy is being investigated as an adjuvant treatment for intracranial neoplasms. The efficacy of this therapy is based on the uptake of photosensitizer by neoplastic tissue, its clearance from surrounding brain tissue, and the timing and placement of photoactivating sources. Photofrin-II is the photosensitizer most actively being investigated. We labeled Photofrin-II with Indium-111 and studied the uptake and distribution of this agent in 20 patients with intracranial neoplasms, using single photon emission computed tomography (SPECT) with volume rendering in three dimensions. Of these patients, 16 had malignant glial tumors, 2 had metastatic deposits, 1 had a chordoma, and 1 had a meningioma. Anatomical-spatial data correlated well between the SPECT images and contrast-enhanced computed tomography or magnetic resonance images. Regions of focal uptake on SPECT images correlated with the surgical histopathological findings of the neoplasm. The kinetics of photosensitizer uptake varied according to the tumor's histological findings, the patient's use of steroids, and among patients with similar types of tumor histology. Peak ratios of target-to-nontarget tissue varied from 24 to 72 hours after injection. The study data show that, to be most effective, photodynamic therapy may need to be tailored for each patient by correlating SPECT images with anatomical data produced by computed tomography or magnetic resonance images. Photoactivating sources then can be placed, using computer-assisted stereotactics, to activate a prescribed volume of photosensitized tumor at the optimal time for treatment.
Adult↗