Faculty Bibliography

BACKGROUND: High-flow intracranial arteriovenous (AV) fistulas associated with giant varices are rare lesions. These varices can present with symptoms from mass effect, spontaneous hemorrhage, and seizures to cardiac failure. Direct AV fistulas of the posterior inferior cerebellar artery (PICA) are extremely rare lesions, with only two cases reported in the literature. CASE DESCRIPTION: The authors present an unusual case of a 25-year-old male with a direct AV fistula of the PICA that resulted from a fracture of the occipital condyle. This high-flow AV fistula drained into a giant varix of the vein of the lateral recess that compressed the brainstem, resulting in a Wallenberg syndrome. The patient underwent embolization of the proximal PICA feeding the fistula with a Guglielmi detachable coil (GDC), which resulted in thrombosis of the varix. A postembolization angiogram showed occlusion of the PICA AV fistula and draining varix. A computed tomography (CT) scan performed at a 10-month follow-up visit showed dramatic decompression of the brainstem. Although the patient continued to have some sensory changes secondary to Wallenberg syndrome, he was otherwise doing well neurologically. CONCLUSION: The treatment of this lesion is difficult because of its location near the brainstem. Postocclusion edema or hemorrhage can result in mass effect and life-threatening brainstem compression. Our patient, whose AV fistula was caused by trauma, was treated effectively with GDC embolization

OBJECT: In a review of the literature, the authors provide an overview of various techniques that have evolved for reconstruction and stabilization after resection for metastatic disease in the subaxial cervical spine. METHODS: Reconstruction and stabilization of the cervical spine after vertebral body (VB) resection for metastatic tumor is an important goal in the surgical management of spinal metastasis. Generally, the VB defect is reconstructed with bone autograft or allograft, polymethylmethacrylate (PMMA), interbody spacers, and/or cages. In cases of PMMA-assisted reconstruction, internal devices are used to augment the fixation of PMMA. Stabilization is then achieved with anterior instrumentation, usually an anterior cervical locking plate. In some cases, posterior instrumentation may be necessary to supplement the anterior construct. CONCLUSIONS: Anterior cervical corpectomy followed by reconstruction and stabilization is an effective strategy in the management of spinal metastases in patients

OBJECTIVES: We evaluated the specific pattern of pre- and postoperative neurological signs and symptoms and functional results in patients with cervical spondylotic myelopathy who underwent anterior decompressive operations. Additionally, we sought to determine which findings had predictive value for surgical outcome. METHODS: We retrospectively reviewed the records of 76 patients with cervical spondylotic myelopathy caused by osteophytic ridge or intervertebral disc herniation who underwent anterior cervical decompression and fusion performed by one surgeon. The patients were evaluated postoperatively by office visits and/or telephone interviews. Outcome was assessed by objective neurological examination and scoring with multiple functional rating scales. RESULTS: The most common preoperative symptoms were deterioration of hand use (75%), upper extremity sensory complaints (82.9%), and gait difficulties (80.3%). In the upper extremities, preoperative weakness was most common in the hand intrinsic muscles (56.6%) and triceps (28.9%), and in the lower extremities, preoperative weakness was most common in the iliopsoas (38.8%) and quadriceps (26.3%). In the lower extremities, individual muscle groups had strength improvement rates from 79.1 to 88.1 %; somewhat higher rates, from 81.3 to 90.9%, were observed in the upper extremities. When evaluated by using the Cooper myelopathy scale, lower extremity functional improvement occurred in 46.7% of the patients and upper extremity functional improvement in 75.4%. Overall functional improvement, evaluated by using a modification of the Japanese Orthopedic Association Scale, was noted in 79.7% of the patients who had abnormal scores preoperatively. CONCLUSION: Strength improved at rates of approximately 80 to 90% in individual muscle groups after anterior cervical decompression. However, fewer than half of all patients experienced functional improvement in the lower extremities, a discrepancy that was probably caused by persistent spasticity rather than muscle weakness. Postoperative dysfunction in the upper extremities was caused by residual weakness as well as sensory loss. Recurrent symptomatic spondylosis at unoperated levels was calculated to occur at an incidence of 2% per year

OBJECTIVE AND IMPORTANCE: We present a patient who experienced a subarachnoid hemorrhage secondary to a dissecting aneurysm of the right posteroinferior cerebellar artery (PICA). The use of an encircling clip in treating the aneurysm while preserving supply to brain stem perforators originating near the dissecting segment and the distal PICA territory was key in the operative management. CLINICAL PRESENTATION: A 48-year-old patient with a history of hypertension presented with subarachnoid hemorrhage confirmed by computed tomography of the brain. Successive cerebral angiography revealed a dynamic change in the configuration of the dissection, with expansion of the associated focal ectasia. OPERATIVE MANAGEMENT: At surgery, three brain stem perforators adjacent to the aneurysm were visualized. The dissecting segment was reconstructed with an encircling Sundt clip and muslin wrap, which preserved the flow through the PICA and brain stem perforators. CONCLUSION: A patient suffering from a dissecting PICA aneurysm and subarachnoid hemorrhage was successfully treated with direct surgical reconstruction of the parent artery, sparing the perforators to the medulla

The clinical findings and computerized tomography (CT) brain scans of 45 patients with supratentorial intracerebral hematomas were evaluated to determine the effect of hematoma location on the clinical course and outcome of the disease. The lesions were frontal in 18 patients, temporal or temporoparietal in 17, and parieto-occipital in 10. No patient with a frontal or parieto-occipital hematoma had clinical signs of transtentorial herniation at admission or subsequently, whereas seven (41%) of those with temporal or temporoparietal lesions had signs of herniation (p less than 0.05); three of these seven patients had an abnormal mental status, ipsilateral anisocoria, and lateralizing motor findings at admission, and four developed these signs within 12 hours after admission, necessitating urgent surgical intervention. The mean volume of the lesions estimated from the CT scans was similar in the three groups (frontal 47 +/- 28 cc; parieto-occipital 53 +/- 26 cc; temporal/temporoparietal 41 +/- 21 cc). None of the six patients with temporal or temporoparietal hematomas smaller than 30 cc had signs of tentorial herniation, compared with seven (64%) of 11 patients with larger hematomas (p less than 0.05); in six of these seven cases, the hematoma was caused by head injury. Patients with a temporal or temporoparietal hematoma had a worse outcome than those in the other two groups, and no patient with signs of tentorial herniation had a good outcome. Patients with temporal or temporoparietal hematomas appear to be at greater risk of brain-stem compression, especially if the lesion is larger than 30 cc and caused by head injury, than are those with hematomas in other sites. In such cases, prompt surgical intervention should be considered