Preoperative Neurological Deficits Research Articles

An Analysis of 32 Surgically Managed Penetrating Carotid Artery Injuries

A review of the surgical management of penetrating carotid artery injuries in the Trauma Unit at Groote Schuur Hospital, Cape Town, is presented.Materials and Methods: a retrospective analysis of all surgically treated penetrating carotid artery injuries over a 3-year period was performed. The policy is to repair all injuries to the common and internal carotid arteries. Ligation is reserved for patients with prolonged coma; ischaemic infarcts or cerebral oedema on computerised axial tomography of the brain; technically inaccessible high internal carotid artery injuries, and those with occluded arteries with no distal patency detected during surgery or with angiography.Results: thirty-two patients with penetrating carotid artery injuries were reviewed. Eleven patients underwent emergency exploration. Twenty-one patients had angiography prior to exploration. Injuries in the emergency group were all repaired, with improvement in level of consciousness; also, two patients had preoperative neurological deficits that improved. Three of the 21 patients in the urgent group underwent ligation of the common carotid artery: one comatose patient with a hemiparesis died following ligation; the other two had improvement in their level of consciousness, one of whom showed improvement of his hemiparesis. The remaining injuries to the common and internal carotid arteries were repaired with improvement in level of consciousness and neurological deficit when present.Conclusion: operative repair offers the best chance of recovery.

Magnetic resonance imaging confirmation of resolution of periodontoid pannus formation following C1/C2 posterior transarticular screw fixation

Chronic odontoid fractures are considered unstable spinal lesions. Chronic instability in this region leads to the development of an inflammatory pannus, which can progress resulting in spinal cord compression radiographically and a myelopathy syndrome clinically. In this report we document three cases of reversal of pannus after C1/C2 transarticular screw fixation of an unstable odontoid fracture. Three patients were identified with chronic odontoid fractures and spinal cord compression due to periodontoid pannus formation. All patients presented with a progressive myelopathy syndrome. All patients underwent preoperative and postoperative magnetic resonance imaging (MRI) of the craniovertebral junction. C1/C2 transarticular screw fixation was performed for stabilization of C1/C2. Postoperatively there were no complications. Postoperative MRI at 6 months demonstrated resolution of the ventral pannus. Moreover, all patients exhibited improvement of preoperative neurological deficits. MRI is the imaging technique of choice for diagnosis and follow-up of patients with chronic odontoid fractures and ventral pannus. C1/C2 transarticular screw fixation provides a viable method for spinal stabilization in this region. In addition, stabilization can result in resolution of inflammatory pannus formation secondary to instability of the C1/C2 articulation.

Localisation of the sensorimotor cortex during surgery for brain tumours: feasibility and waveform patterns of somatosensory evoked potentials

Objective: Intraoperative localisation of the sensorimotor cortex using the phase reversal of somatosensory evoked potentials (SEPs) is an essential tool for surgery in and around the perirolandic gyri, but unsuccessful...

Anterior cervicothoracic junction corpectomy and plate fixation without sternotomy

Exposure of the lower cervical and upper thoracic spinal regions through a cervical incision without sternotomy has been described in cases of anterior decompression and methylmethacrylate vertebral body reconstruction. The use of anterior instrumentation and structural bone grafts in this procedure has not been well described. Twenty-one patients underwent anterior cervicothoracic decompression, fusion, and fixation via a low cervical approach. Eight of these patients underwent lower cervical or upper thoracic corpectomy (C7-T4) through the cervical incision. The decompressive procedure was followed by placement of an allograft bone strut and an anterior locking plate system. No patient developed new neurological deficit related to the spinal cord or exiting nerve roots. Three of four patients with preoperative neurological deficits improved dramatically. Two patients developed recurrent laryngeal nerve palsy, of which one was permanent. There was one case of instrumentation-related failure, and two patients developed a superficial wound infection related to a posterior incision made as part of a 360 degrees fusion. Patients were followed for a mean of 18.5 months (range 2-30 months). Two patients died (of metastatic cancer, and a motor vehicle accident, respectively) during the follow-up period. Anterior decompression, fusion, and fixation is feasible via a cervical incision. This procedural approach spares the patient the morbidity associated with sternotomy or the lateral extracavitary approach. A thorough preoperative assessment of mediastinal anatomy is essential for the safe execution of these procedures.

Long-term oncological results in 47 cases of jugular paraganglioma surgery with special emphasis on the facial nerve issue.

Oncological and functional results were assessed in 47 type C and/or D jugular paraganglioma operated on between 1984 and 1998 using the classical infratemporal fossa type A approach (mean follow-up = 66 months). In 24 instances, however, the facial nerve was not re-routed. Total resection was achieved in 33 cases (70 per cent). In 25 patients available for follow-up this resulted in a 92 per cent cure rate while two patients (eight per cent) developed recurrences that are being followed-up clinically and radiologically. Sub-total resection, leaving infracentimetric tumour remnants after being coagulated, was achieved in 14 cases (30 per cent). In 11 patients available for follow-up, only three cases developed tumour regrowth (27 per cent) that was controlled by salvage irradiation or surgery while in the other cases tumour remnants remained stable (73 per cent). Symptomatic post-operative lower cranial nerve impairment was observed in 23 per cent. When results were analysed depending on whether the facial nerve had been re-routed (n = 18) or not (n = 24), the incidence of facial paralysis HB grade III or more at one year was 33 per cent and eight per cent, respectively. Total resection was achieved in 56 per cent when the facial nerve was re-routed versus 75 per cent when it was not, the difference being due to a higher incidence of large tumours in the first group. The present study suggests that: 1) surgical resection of jugular paraganglioma provides overall satisfactory results, i.e. a 86 per cent rate of either cure or tumour remnant stabilization, but carries a significant risk of iatrogeny; 2) complete tumour removal should not be attempted, especially in patients over 60 years of age with no pre-operative neurological deficits, since leaving infracentimetric tumour remnants has no major detrimental effect on the final outcome; 3) facial nerve transposition carries a significant risk of cosmetic sequelae while it does not provide significant advantages in terms of tumour resection and long-term oncological control.

Posterior Wall Fractures of the Acetabulum: Characteristics, Management, Prognosis

.A consecutive series of 60 fractures of the posterior wall of the acetabulum, treated operatively in a Level I Trauma center is reviewed retrospectively. Characteristics of the lesion, type of treatment, early and late postoperative complications and two-year functional results were recorded. In 27 patients (45%), additional damage to the cartilage of the acetabular cavity such as subchondral impaction, free articular fragments or separation of the posterior wall into several pieces was present. Seven patients (11.6%) showed preoperative neurological deficit. All fractures were treated with open reduction and internal fixation through a Kocher-Langenbeck approach. Secondary nerve damage was present in 8.3%. Early secondary surgery was necessary in 8.3%. During the first two years, additional surgery was performed in 7 patients (15.2%). The rate of periarticular ossifications was 26.1%. The rate of excellent and good results was 69.5%.The posterior wall fracture of the acetabulum is a more complex injury than generally is accepted. A large variety of articular lesions with varying degree of complexity is collected in this fracture type. Even in experienced handspexcellent and good long-term results will not exceed 75%. Poor results are due to suboptimal reconstruction of the posterior wall, partial osteonecrosis and/or complications of the Kocher-Langenbeck approach.

A new application of TCE-MEP: spinal cord monitoring in patients with severe neuromuscular weakness undergoing corrective spine surgery.

The importance of spinal cord monitoring during corrective scoliosis surgery is widely acknowledged. However, for patients with preoperative neurologic deficits, its use is technically difficult. In this article, we describe intraoperative transcranial electrical motor evoked potential (TCE-MEP) monitoring in nine patients with neuromuscular weakness who underwent corrective scoliosis surgery. In each patient, eight muscle groups were recorded and stable responses were obtained in all patients. We conclude that TCE-MEP permits monitoring of the spinal cord in patients with disturbed motor function.

Surgical management of idiopathic spinal cord herniation: a review of nine cases treated by the enlargement of the dural defect.

Spinal cord herniation is a rare cause of progressive myelopathy and can be corrected surgically. In most previous reports, closure of the dural defect was the recommended procedure. The object of this paper is to describe a new procedure in which spinal cord constriction is released by enlarging the hiatus; additionally the postoperative results will be discussed. In nine patients with spinal cord herniation, enlargement of the dural defect was performed. In eight patients, neurological deficits resolved immediately after surgery. In one patient with a severe preoperative neurological deficit whose spinal cord herniated massively, deterioration occurred postoperatively. To date, no recurrence of herniation has been observed. The goals of surgery are to reduce the herniation, return the spinal cord to the normal position, and prevent the recurrence of herniation. The use of sutures to close the dural defect has been the method of choice to date. The surgical space in front of the spinal cord, however, is insufficient to accommodate this procedure safely. Because symptoms are caused by the constriction of the spinal cord at the hiatus, surgical expansion of the hiatus allows the goals of surgery to be achieved. This procedure, which is technically easier and less invasive with regard to the vulnerable spinal cord than the closure of the dural defect, could be a viable alternative for the treatment of this rare disease.

New paradigms and improved results for the surgical treatment of acute type A dissection.

To examine the effect of an integrated surgical approach to the treatment of acute type A dissections. Acute type A dissection requires surgery to prevent death from proximal aortic rupture or malperfusion. Most series of the past decade have reported a death rate in the range of 15% to 30%. From January 1994 to March 2001, 104 consecutive patients underwent repair of acute type A dissection. All had an integrated operative management as follows: intraoperative transesophageal echocardiography; hypothermic circulatory arrest (HCA) with retrograde cerebral perfusion (RCP) to replace the aortic arch; HCA established after 5 minutes of electroencephalographic (EEG) silence in neuromonitored patients (66%) or after 45 minutes of cooling in patients who were not neuromonitored (34%); reinforcement of the residual arch tissue with a Teflon felt "neo-media"; cannulation of the arch graft to reestablish cardiopulmonary bypass at the completion of HCA (antegrade graft perfusion); and remodeling of the sinus of Valsalva segments with Teflon felt "neo-media" and aortic valve resuspension (78%) or replacement with a biologic or mechanical valved conduit (22%). Mean age was 59 +/- 15 (range 22-86) years, with 71% men and 13% redo sternotomy after a previous cardiac procedure. Mean cardiopulmonary bypass time was 196 +/- 50 minutes. Mean HCA with RCP time was 42 +/- 12 minutes (range 19-84). Mean cardiac ischemic time was 140 +/- 45 minutes. Eleven percent of patients presented with a preoperative neurologic deficit, and 5% developed a new cerebrovascular accident after dissection repair. The in-hospital death rate was 9%. Excluding the patients who presented neurologically unresponsive or with ongoing cardiopulmonary resuscitation (n = 5), the death rate was 4%. In six patients adverse cerebral outcomes were potentially avoided when immediate surgical fenestration was prompted by a sudden change in the EEG during cooling. Forty-five percent of neuromonitored patients required greater than 30 minutes to achieve EEG silence. The authors have shown that the surgical integration of sinus segment repair or aortic root replacement, the use of EEG monitoring, partial or total arch replacement using RCP, routine antegrade graft perfusion, and the uniform use of transesophageal echocardiography substantially decrease the death and complication rates of acute type A dissection repair.

Aneurysms of the innominate artery: Surgical treatment of 27 patients

Purpose: Aneurysms of the innominate artery (AIA) are widely considered to be a rare entity. We describe our experience with AIAs in the last three decades. Methods: From October 1973 to October 2000, we operated on 27 patients with an AIA. The underlying cause of aneurysm was Takayasu's disease in 7 patients, degenerative disease in 6 patients, syphilis in 5 patients, chronic dissection in 3 patients, trauma in 2 patients, infection in 2 patients, a postoperative complication in 1 patient, and Marfan syndrome in 1 patient. AIA was associated with an aortic aneurysm in 17 patients. Fourteen patients had no symptoms. The remaining patients had symptoms, with thromboembolic complications in 7 patients, pain without rupture in 3 patients, and a ruptured aneurysm in 3 patients. In two patients at high risk for surgery who had a small AIA with embolic complications, a cervical approach was used as a means of performing distal exclusion and crossover bypass. In the remaining 25 patients, a midline sternotomy was used. One patient with a ruptured AIA exsanguinated during sternotomy. Ten patients underwent a prosthetic replacement of the ascending aorta and/or aortic arch with a separate prosthetic branch to the innominate artery (IA). Thirteen patients underwent ascending aorta-to-IA prosthetic bypass in association with lateral suture (8 patients) or prosthetic patching (5 patients) of the aorta. One patient with an infected aneurysm was treated by means of resection of the aneurysm, proximal ligation of the IA, and transposition of the right into the left common carotid artery. Cardiopulmonary bypass with deep hypothermic circulatory arrest was used in 10 patients. Results: Three perioperative deaths occurred (2 of 4 in association with emergency treatment and 1 of 23 with elective treatment). Respiratory complications requiring prolonged artificial ventilation developed in five patients. Two patients had transient worsening of preoperative neurologic deficits. Late results, with a mean follow-up of 85 months, were good. Conclusion: The etiology and presentation of AIAs are variable. Surgical management with current cardiovascular techniques achieves excellent results. (J Vasc Surg 2001;34:222-8.)

Management of penetrating injuries to carotid artery.

The diagnosis and management of penetrating injuries to the cervical carotid arteries continue to be controversial. Most patients with stab or gunshot wounds to the common or internal carotid artery in cervical zone II (sternal notch to angle of mandible) are symptomatic with external or intraoral hemorrhage, a rapidly expanding hematoma, evidence of a carotid-jugular arteriovenous fistula at an obvious site, or loss of the carotid pulse with a neurologic deficit. Immediate airway control and arterial repair are indicated in such patients. Other patients present with stab or gunshot wounds with proximity only to the carotid sheath, a stable hematoma, unknown level of a carotid-jugular arteriovenous fistula, or loss of the carotid pulse without a neurologic deficit. Diagnostic options in this latter group include duplex ultrasound, color duplex imaging, and standard arteriography, while the role of CT or MRI angiography in evaluating patients with penetrating cervical wounds is unclear at this time. Certain arterial injuries discovered on diagnostic tests are currently managed with observation, endovascular stenting (for intimal or wall irregularities), and arteriographic embolization (for small pseudoaneurysms or high carotid-jugular fistulas). Operative repairs for injuries in zone II are performed through an oblique cervical incision and include all the options used with peripheral vascular injuries. Patients with penetrating cervical wounds, preoperative neurologic deficits, and immediate transport to the trauma center should have repair rather than ligation of the injured carotid artery. When the patient is truly comatose with a Glasgow Coma Scale score < 8, an unsatisfactory neurologic outcome is likely with either arterial repair or ligation. Injuries to the extracranial internal carotid artery in cervical zone III (above the angle of the mandible) may require innovative approaches to control hemorrhage and then maintain flow to the ipsilateral cerebral cortex.

Simultaneous anterior-posterior approach to the thoracic and lumbar spine for the radical resection of tumors followed by reconstruction and stabilization.

Thoracic or lumbar spine malignant tumors involving both the anterior and posterior columns represent a complex surgical problem. The authors review the results of treating patients with these lesions in whom surgery was performed via a simultaneous anterior-posterior approach. The hospital records of 26 patients who underwent surgery via simultaneous combined approach for thoracic and lumbar spinal tumors at our institution from July 1994 to March 2000 were reviewed. Surgery was performed with the patients in the lateral decubitus position for the procedure. The technical details are reported. The mean survival determined by Kaplan-Meier analysis was 43.4 months for the 15 patients with primary malignant tumors and 22.5 months for the 11 patients with metastatic spinal disease. At 1 month after surgery, 23 (96%) of 24 patients who complained of pain preoperatively reported improvements (p < 0.001, Wilcoxon signed-rank test), and eight (62%) of 13 patients with preoperative neurological deficits were functionally improved (p = 0.01). There were nine major complications, five minor complications, and no deaths within 30 days of surgery. Two patients (8%) later underwent surgery for recurrent tumor. The simultaneous anterior-posterior approach is a safe and feasible alternative for the exposure tumors of the thoracic and lumbar spine that involve both the anterior and posterior columns. Advantages of the approach include direct visualization of adjacent neurovascular structures, the ability to achieve complete resection of lesions involving all three columns simultaneously (optimizing hemostasis), and the ability to perform excellent dorsal and ventral stabilization in one operative session.

A Comparative Study of Surgical Approaches for Cervical Compressive Myelopathy

Since 1986, the authors have used anterior decompression and fusion to treat patients with one- or two-level lesions without spinal canal stenosis (Group A) and laminoplasty for patients with more than three-level lesions or spinal canal stenosis (Group P). The aim of this study was to compare surgical outcomes of anterior and posterior approaches for patients with cervical myelopathy because of spondylosis and disc herniation and to determine the cause of poor neurologic recovery after surgery. One hundred thirty-six patients were followed up for an average of 5.6 years. There were no significant differences in gender, preoperative neurologic deficits, axial symptoms, or duration of symptoms before surgery between the two groups. Mean recovery rates for disc herniations were 71.1% and 71.9% in Groups A and P, respectively. For spondylosis, mean recovery rates were 49.0% and 58.6% in Groups A and P, respectively. There were no differences in recovery rate for patients with either spinal disorder between Groups A and P. The neurologic recovery of patients with kyphotic spinal cord was inferior to that of patients with lordotic or straight spinal cord. It is possible that acquisition and maintenance of lordosis result in improvement of clinical outcomes after surgery for patients with myelopathy.

Is the Posterior Wall Avulsion the Simplest Acetabular Fracture?

The posterior wall fracture – the most frequent acetabular lesion – is often regarded as the simplest acetabular fracture. In fact, a large variety of complex articular lesions is subsumed under this fracture type. A consecutive series of 60 posterior wall fractures is reviewed retrospectively. Lesions characteristics, treatment method, early and late postoperative complications a 2-year functional results were recorded. In 27 patients (45%), additional damage to the cartilage of the acetabular cavitiy such as subchondral impaction, free articular fragments of separation of the posterior wall into several pieces was present. Seven patients (11.6%) showed preoperative neurologic deficit. Secondary nerve damage was present in 8.3%. During the first 2 years, additional surgery was performed in 7/46 patients (15.2%). The rate of periarticular ossifications amounted to 26.1%. The rate of excellent and good results was 69.5%. Posterior wall fracture of the acetabulum is a more complex injury than generally accepted. The trauma surgeon's task is to complete identify the lesion and to consider all aspects of the injury during surgery and rehabilitation. Even in experienced hand, excellent and good long-term results will not excee 75%. Poor results are due to the difficulty of posterior wall reconstruction, partial osteonecrosis and/or complications caused by the Kocher-Langenbeck approach.

Surgical treatment of brain metastases from melanoma: a retrospective study of 91 patients.

Reports on the surgical treatment of brain metastases from melanoma in a large group of patients are sparse. The goal of this paper is to review the surgical experience in a series of 91 patients with brain metastases from primary melanoma treated at a single institution. Seven hundred eighty patients underwent resection of brain metastases at Memorial Sloan-Kettering Cancer Center between 1974 and 1994. The records of 91 (11.7%) of these patients who had melanoma were retrospectively reviewed. The median time from diagnosis of the primary melanoma to diagnosis of the brain lesion was 14.1 months. The overall median length of survival following craniotomy was 6.7 months. Fifteen patients with resected multiple metastases had shorter median survival times than 76 patients with a single lesion (5.4 months compared with 7.8 months, p = 0.12). In eight patients with cerebellar metastases the median length of survival was significantly shorter than that found in patients with supratentorial lesions (2 compared with 7 months, p = 0.03). There was no difference in length of survival between 49 patients who underwent postoperative whole-brain radiation therapy (WBRT) and 29 patients who did not (9.5 compared with 8.3 months, p = 0.67). The incidence of brain metastasis recurrences in WBRT-treated and untreated patients was similar (56% and 45.7%, respectively). Only the presence of infratentorial metastases (p = 0.0013) and unresected recurrence of brain metastases (p = 0.0003) had an impact on outcome according to a Cox regression analysis. Five patients (5.5%) died within 31 days of surgery. Overall survival rates at 1, 2, 3, and 5 years were 36.3, 18.7, 13.2, and 6.6%, respectively. Although melanoma metastatic to the brain carries a foreboding prognosis, patients who do not display preoperative neurological deficits, harbor a single lesion situated supratentorially, and have no lung or visceral metastases may derive significant palliative benefit from surgical resection of brain metastases.

Complications of brain stem surgery: Prevention and treatment

With experienced neurosurgical, neuroanesthetic, and intensive care teams, postoperative recovery after brain stem surgery may be uneventful in patients without severe preoperative neurological deficits. The primary goal of postoperative intensive care is to ensure adequate monitoring and maintenance of homeostasis in an effort to prevent systemic and cerebral complications. Nevertheless, systemic complications and postoperative neurological deterioration are common. Respiratory failure, dysphagia, and pulmonary aspiration are possible life-threatening postoperative complications that may occur days or weeks after surgery. Impaired respiratory drive may result in progressive carbon dioxide retention and hypoxia, leading to respiratory arrest. Glossopharyngeal and vagal nerve dysfunction may be associated with high rates of postoperative morbidity and mortality. Damage to these nerves impairs swallowing and protective and coughing reflexes and may result in dysphagia, vocal cord paralysis, and gastric stasis. A comprehensive assessment (qualitative and quantitative) of possible swallowing deficits is important before and after extubation, particularly at early extubation trials, in an effort to prevent major postoperative complications. If a swallowing deficit is underestimated, dramatic episodes of aspiration may occur with acute respiratory failure or pulmonary edema. Continuous subclinical pulmonary inhalation predisposes the patient to sepsis and multiple organ failure. Treatment of dysphagia is complex and requires a multidisciplinary team to evaluate the most feasible therapeutic option for the patient to ensure adequate and safe separation of airways and food passages. Expert medical and nursing care consists of experienced, dedicated, and professional personnel who are aware of the strict relationship among intensive care treatment, prevention of complications, and the possibility of recovery.

Chronological changes in mri findings of spinal dural arteriovenous fistula

BACKGROUND Intramedullary high-intensity changes on T2-weighted magnetic resonance images (MRI) occur in patients with spinal dural arteriovenous fistulas (AVF). Reduction of the high-intensity area after treatment has been noted; however, there are still questions about whether the change is related to preoperative clinical grade, postoperative improvement, or efficacy of treatment. This study tried to clarify the relationship between chronological changes in the high intensity area with the treatment and clinical course. METHODS Chronological changes in an intramedullary high-intensity area after surgery were retrospectively analyzed in recent 13 patients with spinal dural AVFs who were treated and followed by MRI. RESULTS Preoperative intramedullary high-intensity areas were observed on T2-weighted images in all cases. The extent of the high-intensity area correlated with preoperative neurological deficits. The intramedullary high-intensity area was reduced or diminished after successful interruption of AVFs. The high-intensity area started to decrease within 1 to 4 months after treatment in all patients, and disappeared at 2 weeks to 23 months in seven patients. The reduction may suggest interruption of the fistula and improvement of venous circulation, but was not always correlated to clinical improvement. The intramedullary high-intensity areas rapidly disappeared in two patients, but did not clearly correspond to the clinical improvement. CONCLUSIONS The time course of postoperative MRI changes is helpful for evaluating the efficacy of treatment after surgery for spinal dural AVFs.

Moderators of the effect of preoperative emotional adjustment on postoperative depression after surgery for temporal lobe epilepsy.

Other outcome measures besides seizure control must be considered when assessing the benefit of epilepsy surgery. We investigated the effect of preoperative psychosocial adjustment on postoperative depression in epilepsy patients followed up prospectively for 2 years after temporal lobectomy. The Washington Psychosocial Seizure Inventory (WPSI) evaluated psychosocial functioning; the Centre for Epidemiological Studies Depression Scale (CES-D) measured depression. Both were completed at baseline and follow-up. Follow-up occurred in 39 temporal lobectomy patients at 2 years after surgery. Greatest improvement in depression scores was limited to patients with good seizure outcomes (seizure free, or marked reduction in seizure frequency), and seizure outcome was a significant predictor of postoperative depression. Despite this, preoperative scores on the emotional adjustment scale of the WPSI were most highly correlated with depression 2 years after surgery. To clarify this relation, moderated hierarchic regression suggested that good preoperative emotional adjustment (WPSI) was generally associated with less depression after surgery. Moreover, poorer preoperative adjustment combined with older age, generalized seizures, the finding of preoperative neurologic deficits, a family history of psychiatric illness, and/or a family history of seizures was related to higher depression scores 2 years after surgery. Depression after temporal lobectomy is dependent on a complex interaction of variables and can have a significant effect on indices of postoperative adjustment. The WPSI emotional adjustment scale may help to predict which patients are likely to be chronically depressed after surgery.

Craniotomy under local anesthesia and monitored conscious sedation for the resection of tumors involving eloquent cortex.

Resection or even biopsy of an intra-axial mass lesion in close relationship to eloquent cortex carries a major risk of neurological deficit. We have assessed the safety and effectiveness of craniotomy under local anesthesia and monitored conscious sedation for the resection of tumors involving eloquent cortex. We have performed a retrospective review of a consecutive series of 157 adult patients who underwent craniotomy under local anesthesia by one surgeon (P.M.B.) at Brigham and Women's Hospital in Boston. All patients had tumors in close proximity to eloquent cortex, including speech, motor, primary sensory, or visual cortex. In most cases the lesion was considered inoperable by the referring surgeon. All resection was verified by post-operative imaging approximately one month after surgery and all cases were reviewed by an independent neurosurgeon (A.D.). In 122 cases, brain mapping was performed to identify eloquent cortex and in the remainder neurological monitoring was maintained during the procedure. Radiological gross total resection was achieved in 57% of patients and greater than 80% resection was achieved in 23%. Thus 4 out of 5 of patients had major resection despite the close relationship of tumor to eloquent cortex. In 13%, less than 80% of tumor was removed because of danger of neurological deficit. In 7% of patients, only a biopsy could be done because of infiltration into eloquent cortex that could only be assessed at surgery. In 76 patients with pre-operative neurological deficits, there was complete resolution of these deficits in 33%, improvement in 32%, no change in 28%, and long-term worsening in 8%. Among 81 patients with no pre-operative neurological deficit, 1 patient suffered a major permanent neurological deficit, and 2 developed minor deficits. There was a transient post-operative deficit in one-third of cases, but this had resolved at one month in all but three patients. Monitored conscious sedation was performed without anesthetic complications using midazolam, sufentanyl and fentanyl with or without propofol. Only one case needed to be converted to general anesthesia. Patient satisfaction with the procedure has been good. Operating time and hospital stay were lower than the mean for brain tumor craniotomy at this hospital. Tumor surgery with conscious sedation is a safe technique that allows maximal resection of lesions in close anatomical relationship to eloquent cortex, with a low risk of new neurological deficit. Only 7% of intrinsic cortical tumors were ineligible for partial or complete resection with this technique.

Pure sylvian fissure arteriovenous malformations

Pure sylvian fissure arteriovenous malformations (AVMs) are vascular malformations confined to the sylvian fissure without parenchymal involvement. Because the branches of the middle cerebral artery are arteries of passage and the margins between the AVM and the insula cortex may be ill defined, many surgeons regard pure sylvian fissure AVMs as inoperable. The authors reviewed their surgical experience with eight patients harboring pure sylvian fissure AVMs to determine the incidence of operative morbidity. All eight patients experienced seizures, five (63%) had headaches, and three (38%) experienced hemorrhages. Preoperatively, six patients (75%) were normal neurologically and two (25%) had neurological deficits. Five (63%) of eight sylvian fissure AVMs were located in the dominant hemisphere. The size of the nidus ranged from 6 to 27 cm3 (mean 14 cm3). Complete removal of the AVM was documented by postoperative angiography in every case. Seizures were reduced or eliminated and headaches were relieved in all affected patients. Transient neurological deficits, which included aphasia, short-term memory loss, and hemiparesis, occurred in four patients (50%). Within 3 months, all patients were functioning independently with no new neurological deficits. The status of two patients who had had preoperative neurological deficits improved postoperatively. Neuropsychological testing showed no new cognitive deficits. With appreciation for transient instances of postoperative morbidity, the outcome was excellent in all patients. The authors thus advocate microsurgery as the primary treatment for pure sylvian fissure AVMs.