Subarachnoid Adhesions Research Articles

Application of magnetic resonance virtual endoscopy in microvascular decompression of trigeminal neuralgia

Objective To investigate the application value of magnetic resonance virtual endoscopy (MRVE) combined with three-dimensional time-of-flight (3D-TOF) and three-dimensional fast imaging employing steady-state acquisition (3D FIESTA) sequence in the microvascular decompression of trigeminal neuralgia. Methods Seventy-six patients with primary trigeminal neuralgia treated with microvascular decompression (MVD) at the Department of Neurosurgery, Huzhou Central Hospital from August 2012 to April 2015 were enrolled retrospectively. All the causes of disease in the patients were identified during the operations. All patients conducted imaging examinations of 3.0T MRI for 3D-TOF, 3D-FIESTA, and MRVE. The diagnostic and intraoperative values of MRVE combined with 3D-TOF and 3D-FIESTA sequences were evaluated. Results In 76 patients, the preoperative 3D-TOF+ 3D-FIESTA sequences diagnosed 63 patients with offending vascular compression. The coincidence rate with the surgery confirmation was 83% and 13 patients (17%) were missed diagnosis; 3D-TOF+ FIESTA+ MRVE sequences diagnosed 72 patients with offending vascular compression, the coincidence rate was 95%, and 4 were missed diagnosis (5%), P=0.04. The patients of diagnostic coincidence of the 2 kinds of sequences were mainly the arteries as offending vessels. The patients of missed diagnosis were mainly in patients with offending vessels as veins, one of the patients with subarachnoid adhesions and thickening was missed diagnosis. Conclusion MRVE technique combined with 3D-TOF and 3D-FIESTA sequences may clearly reveal the relationship of three-dimensional space between offending vessels and nerves, and improve the accurate rate for identification of offending vessels. Key words: Trigeminal neuralgia; Magnetic resonance imaging; Microvascular decompression surgery; Magnetic resonance virtual endoscopy

LONG-TERM RESULTS OF A SECOND ENDOSCOPIC THIRD VENTRICULOSTOMY IN CHILDREN

To evaluate retrospectively the operative findings and long-term results of a repeat endoscopic third ventriculostomy (ETV) in pediatric hydrocephalic patients readmitted after the first procedure with symptoms and/or signs of intracranial hypertension and/or radiological evidence of increased ventricular dilation and/or occluded stoma on follow-up radiological examinations. We analyzed a series of 482 ETVs in pediatric patients from 2 Italian departments of pediatric neurosurgery. The clinical charts of 40 patients undergoing a second ETV were selected and reviewed retrospectively. The pre- and postoperative radiological findings and operative films were analyzed retrospectively. Forty patients underwent a total of 82 ETVs. Thirty-eight patients were operated on twice and 2 were operated on 3 times. During the second procedure, the stoma was found to be closed in 28 patients without underlying adhesions, to be open but with significant arachnoid adhesions in the prepontine cistern in 8 patients, to be open without adhesions in 2 patients, to have a pinhole orifice in 1 patient, and to be closed with underlying adhesions in 1 patient. The second procedure allowed reopening of the stoma or lysis of the arachnoid adhesions in 35 patients and was abandoned in 3 patients because of extensive arachnoid adhesions or because the stoma was found to be wide open (2 patients). In 30 patients (75%), the second ETV was effective, and the 2 patients who underwent a third ETV remained shunt free. In 10 patients (25%), a ventriculoperitoneal shunt was eventually placed. Age younger than 2 years at the time of the first procedure and arachnoid adhesions in the subarachnoid cisterns observed during the second procedure are the main negative prognostic factors for the success of a second ETV. A second ETV can be performed with a reasonable chance of restoring patency of the stoma and avoiding placement of an extrathecal shunt. Every effort should be made to detect subarachnoid adhesions in the cistern on preoperative imaging study to select potential candidates and avoid unnecessary procedures.

Chronic myelopathy due to a giant spinal arachnoid cyst: a complication of the intrathecal injection of phenol

Acquired intradural arachnoid cystic lesions of the spine have been associated with trauma, hemorrhage, parasitic infections, and other insults that cause inflammation and subarachnoid adhesions. The authors describe the case of a previously healthy 36-year-old woman who presented with a chronic myelopathy due to the progressive development of a giant spinal arachnoid cyst that resulted after the intrathecal injection of phenol for the management of chronic upper extremity pain. Neurological examination, spinal computed tomography, and magnetic resonance imaging were used for diagnostic and follow-up purposes. Even after the initial excision of the cyst, the patient remained symptomatic with minimal functional recovery.

Managing chronic headaches in the clinic

To the Editor: In their recent article, Managing chronic headaches in the clinic (Int J Clin Pract 2004; 58(12):1142–51), Dowson et al. suggest that some types of headaches may not be well recognized or well treated. They discuss management algorithms, and state that ‘principles can be customized to the headache subtype by the selection of appropriate therapies’. Successful personalized treatment is a highly desirable, attainable goal that is dependent on accurate evaluation of the problem. Engineers know that the type of a problem's source predicts its appropriate type of solution: chemical problems respond best to chemical solutions, and mechanical problems respond best to mechanical solutions. Many chronic daily headache (CDH) cases have a mechanical source, and as such, cannot be treated effectively with biochemical medications. Therefore, an effective management algorithm includes the directive: obtain magnetic resonance imaging (MRI) of CDH patients to identify treatable structural causes. Case in point: since 1999, with the publication of ‘Chiari 1 malformation redefined: clinical and radiographic findings for 364 symptomatic patients’ (Neurosurgery 1999; 44(5): 1005–17), a landmark study by Milhorat et al., it has become very clear that many chronic headaches are the result of compression of the hindbrain. A volumetrically small posterior fossa crowded with a normal-sized brain restricts cerebrospinal fluid flow dynamics, as measurable by both cine MRI and colour Doppler ultrasonography (CDU). Patients with such flow restrictions and tissue compression suffer from an increased intracranial pressure, and from impaired function of affected, compressed brain parts, most notably the cerebellum, occipital lobe and brainstem. (Symptoms number into the several dozen.) Additionally, many of these patients also develop subarachnoid adhesions and abnormal cranial vasculature, and a smaller subset has tonsils that are wrapped around or tethered to the brainstem or spinal cord. Hydrocephalus is not required for the diagnosis, and, in fact, is less common than other equally symptomatic manifestations. In the US, between 200,000 and 2 million people suffer from this clearly mechanical cause of CDH. The vast majority of them are undiagnosed for months or years, and typically are misdiagnosed with migraine, tension headaches, multiple sclerosis, lupus, fibromyalgia or psychiatric disturbances. This would not happen if more primary care physicians, neurologists and pain specialists were very familiar with the devastating manifestations of mechanical hindbrain compression. The treatment for severely symptomatic posterior fossa compression is physical removal of the obstruction(s), creation of adequate space for the brain and restoration of proper CSF flow dynamics. This is accomplished surgically through the widening of the cranial–cervical junction, construction of artificial cisterna magna with attention paid to establishing a 3–5 cm/second bidirectional CSF flow at the cervicomedullary junction, and a collection volume of 8–10 cc of CSF in the new cisterna magna. The recent introduction of the intraoperative use of CDU has made this feat possible and provable. See the article ‘Tailored operative technique for Chiari type I malformation using intraoperative colour Doppler ultrasonography’ (Neurosurgery 2003; 53(4): 899–906). In addition, see http://www.thechiariinstitute.com/chiari_techniques.html. In future explorations within the realm of chronic daily headache, we hope that primary care physicians, neurologists and pain specialists will join forces with their equally dedicated counterparts in the neurosurgical world, and offer a complete picture of possible causes and matching solutions to the many headache sufferers who cross their doorsteps.

Syringo-subarachnoid shunt for syringomyelia using partial hemilaminectomy

Syringo-subarachnoid shunt (S-S shunt) is one of the established surgical procedures for syringomyelia. However, this procedure requires a laminectomy which may lead to spinal column complications.We present a modified form of S-S shunt using a partial hemilaminectomy; a S-S shunt is placed via the dorsal root entry zone into the anterior subarachnoid space which is considered to be an ideal site for the drainage of the syrinx fluid. This technique will decrease the incidence of neuronal and spinal complications after surgery and avoid subarachnoid adhesions around the shunt tube. Between 1992 and 1997, a total of 24 patients with syringomyelia have been treated with this surgical procedure without any complications. Collapse of the syrinx was achieved in all cases.The authors believe that the procedure is an effective surgical treatment for syringomyelia and can be applied safely to adolescent and child cases.

Late sequelae of spinal cord trauma. Myelographic and surgical correlation.

Eighteen patients with posttraumatic paraplegia were examined myelographically at 2 months to 30 years after the injury, and the findings correlated with surgical exploration. The following six myelographic patterns were seen: 1) tethered cord and subarachnoid adhesions; 2) proximal cord cysts; 3) loculated subarachnoid cysts; 4) proximal cord atrophy; 5) extradural fibrosis; and 6) complete obliteration of the subarachnoid space at the level of trauma due to extradural fibrosis and/or bone encroachment on the vertebral canal. Myelography with or without computerized tomography (CT) accurately reflected the gross pathological process. The examination is indicated prior to surgical intervention: the structural lesion in four patients extended two or more vertebral levels above the site of the original bone injury and was not easily predictable preoperatively. When combined with CT, myelography allowed evaluation of the transverse anatomy of the vertebral canal and its contents; it was especially useful when the canal was narrowed or distorted by bone and soft tissue. Water-soluble contrast media provided a more detailed evaluation of the spinal cord and subarachnoid space, and were the preferred agents. If a posttraumatic syrinx is suspected, these are the agents of choice.

Spinal Subarachnoid Hematoma after Lumbar Puncture Producing Acute Thoracic Myelopathy

Abstract A case of subarachnoid hematoma after a difficult lumbar puncture and anticoagulation is presented. Subarachnoid adhesions preventing the free flow of spinal fluid at the T-6 level served to limit the cranial progression of the hemorrhage and produced a transverse myelopathy at that level. The underlying pathology, clinical course, and myelographic findings are reviewed. Pertinent literature is presented.

Spinal Subarachnoid Hematoma after Lumbar Puncture Producing Acute Thoracic Myelopathy

A case of subarachnoid hematoma after a difficult lumbar puncture and anticoagulation is presented. Subarachnoid adhesions preventing the free flow of spinal fluid at the T-6 level served to limit the cranial progression of the hemorrhage and produced a transverse myelopathy at that level. The underlying pathology, clinical course, and myelographic findings are reviewed. Pertinent literature is presented.

Hydrocephalus following removal of cerebellar astrocytomas in children.

✓ Of 150 children undergoing surgery for cerebellar astrocytoma, 20% had evidence of postoperative hydrocephalus. This was manifested by either progressive symptomatic rise in intracranial pressure or abnormal mental and motor states accompanied by normal CSF pressure. This syndrome is presumed to be due to cisternal and subarachnoid adhesions formed after surgery. Prompt shunting in advanced cases resulted in reversal of neurological abnormalities.

The Coronary Insufficiency of Neurogenic Origin with Special Reference to Neurocirculatory Asthenia. : A Clinical Study by means of Exercise Electrocardiograms. (II) : CORRELATION BETWEEN EXERCISE RESPONSES AND MYELOGRAPHIC FINDINGS.

Correlations between the observed exercise responses and the underlying distribution of myelographically suggested subclinical adhesive arachnoiditis were investigated to clarify the possible effect of the spinal sympathetic nervous system on the exercise responses. The most prominent finding concerned the chronotropic effect ; namely, the subarachnoid adhesions occurred with high frequency between D3 and D6 vertebra in the ventral aspect of the spinal cord characteristically in association with excessive cardioacceleration after exercise.

Subarachnoid Spinal Adhesions: An Attempt Experimentally to Produce and Prevent Their Recurrence.

Subarachnoid spinal adhesions may at times produce clinical symptoms. Such a case has been observed by us in which following a laminectomy for paraplegia numerous adhesions of the spinal subarachnoid space were found. These adhesions were divided, but as adhesions involving all serous membranes are apt to recur, the possibility of a recurrence of these subarachnoid adhesions was considered. As Herrmann and Musser, and Ochsner and Herrmann had successfully prevented the recurrence of adhesions in the pericardial cavity and Ochsner and Mason in the peritoneal cavity experimentally by the use of digestants, it was thought possible that such procedures might be employed in the prevention of the recurrence of spinal subarachnoid adhesions. Our purpose in this study was to produce subarachnoid adhesions by introducing an irritant into the spinal subarachnoid space in the lower thoracic region of dogs, later to divide these adhesions, and to attempt to prevent their reformation by introducing a digestion solution. We have been able to find no record of a previous attempt of this kind, although Dr. E. R. Schmidt, of the University of Wisconsin, has employed a digestant in the subarachnoid space in one case in order to attempt to prevent the reformation of adhesions. The experimental animals employed were dogs. An attempt was made to inject the irritant into the spinal subarachnoid space by spinal puncture, but because of the difficulty encountered in performing a lumbar puncture, this method was abandoned. A formal laminectomy was employed in the remainder of the animals, and the irritant was injected into the subarachnoid space by means of a syringe and cannula. The animals were prepared in the usual manner; ether was used as the anesthetic agent.