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Neurosurgical Focus May 2012Spinal arteriovenous malformations (AVMs) are classified into types according to anatomical characteristics: dural arteriovenous fistulas (AVFs), intramedullary AVMs,... (Review)
Review
OBJECT
Spinal arteriovenous malformations (AVMs) are classified into types according to anatomical characteristics: dural arteriovenous fistulas (AVFs), intramedullary AVMs, perimedullary AVFs, and extradural AVFs. Spinal extradural AVFs are much rarer than other types of spinal AVMs, and the available literature on this clinical entity has been based only on case reports or small case series. To investigate the clinical characteristics of patients with spinal extradural AVFs, the authors systematically reviewed the associated literature in the MRI era.
METHODS
The PubMed database was searched for all relevant English-language case reports and case series published from 1990 to 2011. The clinical differences between Type A with and Type B without intradural venous drainage were statistically compared, especially regarding clinical features and angiographic and MRI findings.
RESULTS
Forty-five cases of spinal extradural AVFs were found. Type A spinal extradural AVFs were diagnosed in patients with a significantly older age (mean 63.5 years) as compared with Type B AVFs (mean 34.3 years, p < 0.0001). Most cases of Type A spinal extradural AVFs exhibited a diffuse high signal intensity of the spinal cord on T2-weighted MR images and no mass effect (p < 0.0001), and they commonly occurred in the thoracolumbar and lumbar regions (p < 0.0001). On the other hand, cases of Type B lesions exhibited a normal signal intensity of the cord with severe mass effect due to an enlarged extradural venous plexus, and they commonly occurred in the cervical and upper thoracic regions (p < 0.0001), frequently in patients with neurofibromatosis Type 1 (p = 0.049). Because Type B AVFs consisted of high-flow, multiple complex anastomoses between arteries and the epidural venous plexus, patients with these lesions tended to undergo multisession treatments, and the rate of partial AVF occlusion was significantly higher than for Type A AVFs (p = 0.018), although there was no difference in symptom outcomes between the 2 groups.
CONCLUSIONS
To the best of the authors' knowledge, a comparative analysis of the clinical differences in patients with extradural AVFs with or without intradural venous drainage has yet to be described in the literature. They concluded that in the diagnosis of spinal extradural AVF, evaluation of intradural venous drainage is important because the cause of myelopathy determines the treatment goals.
Topics: Aged; Arteriovenous Malformations; Databases, Bibliographic; Drainage; Dura Mater; Embolization, Therapeutic; Female; Humans; Male; Middle Aged; Spinal Cord
PubMed: 22537134
DOI: 10.3171/2012.2.FOCUS1216 -
The Laryngoscope Feb 2012Systematically review the outcomes of endoscopic endonasal techniques to reconstruct large skull base defects (ESBR). Such surgical innovation is likely to be reported... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES/HYPOTHESIS
Systematically review the outcomes of endoscopic endonasal techniques to reconstruct large skull base defects (ESBR). Such surgical innovation is likely to be reported in case series, retrospective cohorts, or case-control studies rather than higher level evidence.
STUDY DESIGN
Systematic review and meta-analysis.
METHODS
Embase (1980-December 7, 2010) and MEDLINE (1950-November 14, 2010) were searched using a search strategy designed to include any publication on endoscopic endonasal reconstruction of the skull base. A title search selected those articles relevant to the clinical or basic science of an endoscopic approach. A subsequent abstract search selected articles of any defect other than simple cerebrospinal fluid (CSF) fistula, sella only, meningoceles, or simple case reports. The articles selected were subject to full-text review to extract data on perioperative outcomes for ESBR. Surgical technique was used for subgroup analysis.
RESULTS
There were 4,770 articles selected initially, and full-text analysis produced 38 studies with extractable data regarding ESBR. Of these articles, 12 described a vascularized reconstruction, 17 described free graft, and nine were mixed reconstructions. Three had mixed data in clearly defined patient groups that could be used for meta-analysis. The overall CSF leak rate was 11.5% (70/609). This was represented as a 15.6% leak rate (51/326) for free grafts and a 6.7% leak rate (19/283) for the vascularized reconstructions (χ(2) = 11.88, P = .001).
CONCLUSIONS
Current evidence suggests that ESBR with vascularized tissue is associated with a lower rate of CSF leaks compared to free tissue graft and is similar to reported closure rates in open surgical repair.
Topics: Cerebrospinal Fluid Rhinorrhea; Dura Mater; Endoscopy; Humans; Nasal Cavity; Plastic Surgery Procedures; Skull Base; Surgical Flaps
PubMed: 22253060
DOI: 10.1002/lary.22475 -
Neurosurgical Review Apr 2012The cavernous sinus (CS) has one of the most complex anatomical networks of the skull base and because of the diversity of its contents is involved in many pathological... (Review)
Review
The cavernous sinus (CS) has one of the most complex anatomical networks of the skull base and because of the diversity of its contents is involved in many pathological processes. Nevertheless, anatomical literature concerning the CS is still controversial, so a systematic literature review was performed to find out the microanatomy of the medial wall of the CS and its clinical importance on sellar pathologies. Experimental studies from English-language literature between 1996 and 2010 were identified in MEDLINE, LILACS, and Cochrane databases. After analysis, two tables were prepared exhibiting the major points of each article. Fourteen experimental studies were included in the tables. Four studies concluded that the medial wall of the CS is composed of a loose, fibrous structure, and the remaining ten presumed that the medial wall is formed by a dural layer that constitutes the lateral wall of the sella. The lack of definition standards and of methodological criteria led to variation in the results among different studies. Thus, this hindered results comparison, possibly explaining the different observations.
Topics: Cavernous Sinus; Dura Mater; Humans; Pituitary Gland; Reference Values; Sella Turcica
PubMed: 22009493
DOI: 10.1007/s10143-011-0360-3 -
Journal of Neurointerventional Surgery Sep 2011Cervical hemangiopericytoma (HPC) is a rare tumor involving dura and bone. Because HPC shares some imaging features with meningioma, hemangioblastoma, schwannoma and... (Review)
Review
Cervical hemangiopericytoma (HPC) is a rare tumor involving dura and bone. Because HPC shares some imaging features with meningioma, hemangioblastoma, schwannoma and solitary fibrous tumors; histology with appropriate immunohistochemistry is essential for its diagnosis and treatment. HPC is highly vascular and has a high rate of local recurrence following resection. Thus it can pose significant therapeutic challenges. To the best of our knowledge this is the 13th reported case of HPC of the cervical spine and the first case of cervical HPC treated using embolization with Onyx-18. In addition, a systematic review of the literature is presented describing previous experience with HPC of the cervical region. The case of a 61-year-old woman is reported who presented with a 7 month history of dizziness, mild ataxia and left-sided tinnitus when supine. MRI of the cervical spine demonstrated a gadolinium enhancing mass arising from the dorsal cervical dura, extending from the occiput to C2, with internal flow voids and extension into the C2 lamina and spinous process. Digital subtraction angiography demonstrated multiple corkscrew-shaped supplying vessels, marked hypervascularity, rapid arteriovenous shunting and delayed contrast washout. Super selective injection of Onyx-18 yielded approximately 90% embolization of the lesion, followed by subtotal resection and radiotherapy. Histology confirmed the presumptive diagnosis of HPC. Preoperative embolization with Onyx-18 should be considered for large HPC as it may decrease the risk of intraoperative hemorrhage. In this case, embolization with Onyx-18 did not preclude histopathologic diagnosis of HPC.
Topics: Angiography, Digital Subtraction; Cervical Vertebrae; Drug Combinations; Dura Mater; Embolization, Therapeutic; Female; Hemangiopericytoma; Humans; Middle Aged; Polyvinyls; Spinal Neoplasms; Tantalum; Vertebral Artery
PubMed: 21990849
DOI: 10.1136/jnis.2010.003756 -
The Cochrane Database of Systematic... Jan 2011Traditional suburethral slings are surgical operations used to treat women with symptoms of stress urinary incontinence. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Traditional suburethral slings are surgical operations used to treat women with symptoms of stress urinary incontinence.
OBJECTIVES
To determine the effects of traditional suburethral slings on stress or mixed incontinence in comparison with other management options.
SEARCH STRATEGY
We searched the Cochrane Incontinence Group Specialised Register (searched 3 June 2010) and the reference lists of relevant articles.
SELECTION CRITERIA
Randomised or quasi-randomised trials that included traditional suburethral slings for the treatment of stress or mixed urinary incontinence.
DATA COLLECTION AND ANALYSIS
At least three reviewers independently extracted data from included trials onto a standard form and assessed trial methodological quality. The data abstracted were relevant to predetermined outcome measures. Where appropriate, a summary statistic was calculated: a relative risk for dichotomous data and a weighted mean difference for continuous data.
MAIN RESULTS
Twenty six trials involving 2284 women were included. The quality of evidence was moderate for most trials and there was generally short follow-up ranging from 6-24 months.One medium sized trial compared traditional suburethral sling operations with oxybutynin in the treatment of mixed urinary incontinence patients. Surgery appeared to be more effective than drugs in treating patient-reported incontinence (n = 75, Risk Ratio (RR) 0.18, 95% Confidence Interval (CI) 0.08 to 0.43).One trial found that traditional slings were more effective than transurethral injectable treatment (RR for clinician-assessed incontinence within a year 0.21; 95% CI 0.09 to 0.21), and also cheaper on average cost.Seven trials compared slings with open abdominal retropubic colposuspension. Patient-reported incontinence was lower with the slings after one year (RR 0.75; 95% CI 0.62 to 0.90), but not when assessed by clinicians. Colposuspension, however, was associated with fewer peri-operative complications, shorter duration of use of indwelling catheter and less long term voiding dysfunction. One study showed there was a 20% lower risk of bladder perforation with the sling procedure but a 50% increase in urinary tract infection with the sling procedure compared with colposuspension. Fewer women developed prolapse after slings (compared with after colposuspension) in two small trials but this did not reach statistical significance.Twelve trials addressed the comparison between traditional sling operations and minimally invasive sling operations.These seemed to be equally effective in the short term (RR for incontinence within first year 0.97; 95% CI 0.78 to 1.20) but minimally invasive slings had a shorter operating time, fewer peri-operative complications (other than bladder perforation) and some evidence of less post-operative voiding dysfunction and detrusor symptoms.Six trials compared one type of traditional sling with another. Materials included porcine dermis, lyophilised dura mater, fascia lata, vaginal wall, autologous dermis and rectus fascia. Patient-reported improvement rates within the first year favoured the traditional autologous material rectus fascia over other biological materials (RR 0.45; 95% CI 0.21 to 0.98). There were more complications with the use of non-absorbable Goretex in one trial.Data for comparison of bladder neck needle suspension with suburethral slings were inconclusive because they came from a single trial with a small specialised population.No trials compared traditional suburethral slings with anterior repair, laparoscopic retropubic colposuspension or artificial sphincters. Most trials did not distinguish between women having surgery for primary or recurrent incontinence when reporting patient characteristics.For most of the comparisons, clinically important differences could not be ruled out.
AUTHORS' CONCLUSIONS
Traditional slings seem to be as effective as minimally invasive slings, but had higher rates of adverse effects. This should be interpreted with some caution however, as the quality of evidence for the studies was variable, follow-up short and populations small, particularly for identifying complication rates. Tradional sling procedures appeared to confer a similar cure rate in comparison to open retropubic colposuspension, but the long term adverse event profile is still unclear. Reliable evidence to clarify whether or not traditional suburethral slings may be better or worse than other surgical or conservative management options is lacking.
Topics: Adult; Female; Humans; Polytetrafluoroethylene; Randomized Controlled Trials as Topic; Suburethral Slings; Urinary Incontinence; Urinary Incontinence, Stress
PubMed: 21249648
DOI: 10.1002/14651858.CD001754.pub3 -
Neurosurgery Apr 2011To report the clinical presentation and management of an intracranial frontoparietal malignant peripheral nerve sheath tumor (MPNST) and its recurrence in a 6-year-old... (Review)
Review
BACKGROUND AND IMPORTANCE
To report the clinical presentation and management of an intracranial frontoparietal malignant peripheral nerve sheath tumor (MPNST) and its recurrence in a 6-year-old girl, along with a systematic review of the literature.
CLINICAL PRESENTATION
A previously healthy 6-year-old girl presented with severe signs of increased intracranial pressure. Magnetic resonance imaging (MRI) revealed a large heterogeneously enhancing mass at the right frontoparietal convexity. The tumor was completely removed, the histological diagnosis was MPNST, and the patient underwent adjuvant radio- and chemotherapy. Fifteen months later, MRI revealed a small local recurrence. After upfront chemotherapy, the recurrence was removed in a radical, ie, true oncological, neuronavigationally guided, en bloc resection, including approximately 1 cm surrounding gray and white matter and overlying dura mater. Neuropathological examination revealed tumor-free margins. The patient again received adjuvant chemotherapy. Four years after diagnosis and 20 months after cessation of adjuvant therapy, there are no signs of tumor recurrence. The literature search resulted in 17 cases of intracranial MPNSTs not associated with cranial nerves. Despite macroscopically complete resection in many cases and adjuvant radio- and chemotherapy, overall survival was poor, with only 5 patients still alive upon publication (including the current patient).
CONCLUSION
Intracranial MPNSTs not associated with cranial nerves are extremely rare and highly malignant tumors with poor overall survival, probably because of infiltrating growth into surrounding brain tissue. We therefore advocate consideration of nonconventional true oncological en bloc resection when approaching this rare tumor or its recurrence.
Topics: Brain Neoplasms; Child; Female; Humans; Neoplasm Recurrence, Local; Nerve Sheath Neoplasms
PubMed: 21242836
DOI: 10.1227/NEU.0b013e31820a1599 -
British Journal of Anaesthesia Sep 2010No clear consensus exists on how to best prevent severe headache from occurring after accidental dural puncture. We conducted a quantitative systematic review to... (Meta-Analysis)
Meta-Analysis Review
No clear consensus exists on how to best prevent severe headache from occurring after accidental dural puncture. We conducted a quantitative systematic review to identify all available evidence for the prevention of postdural puncture headache (PDPH) and included 17 studies with 1264 patients investigating prophylactic epidural blood patch (PEBP), epidural morphine, intrathecal catheters, and epidural or intrathecal saline. The relative risk (RR) for headache after PEBP was 0.48 [95% confidence interval (CI): 0.23-0.99] in five non-randomized controlled trials (non-RCTs) and 0.32 (0.10-1.03) in four randomized controlled trials (RCTs). The RR for epidural morphine (based on a single RCT) was 0.25 (0.08-0.78). All other interventions were based on non-RCTs and failed statistical significance, including long-term intrathecal catheters with an RR of 0.21 (0.02-2.65). There are a number of promising options to prevent PDPH, yet heterogeneity between the studies and publication bias towards small non-RCTs with positive results limits the available evidence. Thus, a large multicentre RCT is needed to determine the best preventative practices.
Topics: Analgesics, Opioid; Anesthesia, Epidural; Blood Patch, Epidural; Catheterization, Peripheral; Dura Mater; Humans; Morphine; Post-Dural Puncture Headache; Sodium Chloride
PubMed: 20682567
DOI: 10.1093/bja/aeq191 -
European Journal of Radiology Nov 2011Intracranial metastases are a rare manifestation of prostate carcinoma and the dura mater is the most affected site. We report a series of six patients with dural... (Review)
Review
Intracranial metastases are a rare manifestation of prostate carcinoma and the dura mater is the most affected site. We report a series of six patients with dural prostate metastases (DPM) and perform a systematic review of the current literature in order to depict imaging trademarks of this condition. This review points to a magnetic resonance imaging (MRI) pattern of meningeal involvement characterized by a diffuse smooth thickening, nodular appearance or dural-based masses. We also demonstrate an osteoblastic pattern of lesions, particularly in sphenoid wing, by computed tomography (CT) scans. We suggest that these imaging findings may support an elevated index of suspicion of DPM in elderly men, including those patients without urologic symptoms.
Topics: Aged; Dura Mater; Humans; Magnetic Resonance Imaging; Male; Meningeal Neoplasms; Middle Aged; Prostatic Neoplasms; Tomography, X-Ray Computed
PubMed: 20619564
DOI: 10.1016/j.ejrad.2010.06.007 -
Journal of Neuro-oncology Oct 2010Bone involvement is a common finding in many types of lymphoma (Clin Oncol 9(3): 195-196, 1997). However, cranial vault affliction has been regarded as an exceedingly... (Review)
Review
Bone involvement is a common finding in many types of lymphoma (Clin Oncol 9(3): 195-196, 1997). However, cranial vault affliction has been regarded as an exceedingly rare presentation, particularly in the case of primary lymphoma (J Neurosurg 108(5): 1018-1020, 2008). Our objective is to describe a series of five immunocompetent patients with histologically confirmed cranial vault lymphoma (CVL), and to conduct a systematic review of the current literature. Our review points out identical imaging patterns in most of the lesions for all reported CVL cases, despite their different histological subtypes. This typical pattern can be seen on computed tomography (CT) scans and magnetic resonance imaging (MRI) as an expansive tumor that affects all three compartments of the cranial vault, including the scalp, skull bone, and pachymeninges, even in the absence of osteolysis. We argue that the absence of osteolysis might enhance diagnostic capability. In the appropriate clinical setting, these features represent important disease characteristics that may help with an earlier diagnosis. Large B-cell lymphoma was the most common subtype of primary CVL.
Topics: Adolescent; Adult; Aged; Dura Mater; Female; Humans; Immunocompetence; Lymphoma; Magnetic Resonance Imaging; Male; Middle Aged; PubMed; Scalp; Skull; Tomography, X-Ray Computed
PubMed: 20146083
DOI: 10.1007/s11060-010-0137-5 -
Journal of Neurology Oct 2006Erdheim-Chester disease (ECD) is a rare, non-Langerhans form of histiocytosis of unknown etiology that affects multiple organs. We report 6 cases of ECD with... (Review)
Review
Erdheim-Chester disease (ECD) is a rare, non-Langerhans form of histiocytosis of unknown etiology that affects multiple organs. We report 6 cases of ECD with neurological involvement and neuroradiological abnormalities on brain MRI. A literature review revealed 60 other cases of ECD with neurological involvement. We therefore analyzed 66 ECD patients with neurological involvement. Cerebellar and pyramidal syndromes were the most frequent clinical manifestations (41% and 45% of cases), but seizures, headaches, neuropsychiatric or cognitive troubles, sensory disturbances, cranial nerve paralysis or asymptomatic lesions were also reported. Neurological manifestations were always associated with other organ involvement, especially of bones (at least 86%) and diabetes insipidus (47%). Neurological involvement was responsible for severe functional handicaps in almost all patients and was responsible for the death of 6 of the 66 patients (9%). Neuroradiological findings could be separated into three patterns: the infiltrative pattern (44%), with widespread lesions, nodules or intracerebral masses, the meningeal pattern (37%), with either thickening of the dura mater or meningioma-like tumors, and the composite pattern (19%), with both infiltrative and meningeal lesions.
Topics: Adult; Disease Progression; Erdheim-Chester Disease; Female; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Radiography; Seizures
PubMed: 17063320
DOI: 10.1007/s00415-006-0160-9