Faculty Bibliography

Local recurrence following radical resection is one of the most common complications of pediatric craniopharyngioma. Only 28 cases of ectopic recurrence of craniopharyngioma have been reported in the literature, and only 13 cases occurred in patients originally treated as children. In this consecutive series of 86 children who underwent radical resection of primary and recurrent craniopharyngiomas, 4 patients (4.7%) experienced ectopic tumor recurrence, accounting for 27% of all recurrences after gross-total resection. The authors report on the successful surgical treatment of these 4 patients and the impact of ectopic craniopharyngioma recurrence on survival

OBJECT: The purpose of this study was to assess the impact of minimal residual calcification without enhancing tumor on the rate of recurrence after gross-total resection (GTR) of craniopharyngioma in children. METHODS: Data were retrospectively collected in 86 patients younger than 21 years of age in whom 103 craniopharyngioma resections were performed by the senior author between 1986 and 2008. Forty-nine patients (27 boys and 22 girls, with a mean age of 8.6 years) fulfilled the criteria for inclusion in this study by having tumor calcification on the preoperative CT scan, undergoing GTR, and having complete postoperative CT and MR imaging and clinical follow-up. RESULTS: Thirteen patients (27%) had residual calcification (< or = 2 mm in 12 patients; 3.5 mm in 1 patient) on their postoperative CT scan. At a mean follow-up of 9.4 years (median 10 years), 2 (15%) of 13 patients with and 10 (28%) of 36 patients without residual calcification experienced tumor recurrence. There were no significant differences between these groups in terms of the duration of follow-up, time to recurrence, rate of recurrence, or recurrence-free survival. CONCLUSIONS: The absence or presence of minimal residual calcification does not have an impact on the risk of recurrence after GTR in pediatric craniopharyngiomas. The authors recommend withholding irradiation or other adjuvant therapy in the setting of minimal residual calcification without enhancing tumor. Close follow-up with frequent serial imaging in all patients after GTR is imperative to identify and treat early recurrence

OBJECT: The object of this study was to identify characteristic preoperative angiographic and MR imaging features of safely resectable insular gliomas and describe the surgical techniques and postoperative clinical outcomes. METHODS: Thirty-eight patients with insular gliomas underwent transsylvian resection between 1995 and 2007. Patient demographics, presenting symptoms, pathological findings, and neurological outcomes were retrospectively reviewed. Preoperative MR imaging-defined tumor volumes were superimposed onto the preoperative stereotactic cerebral angiograms to determine whether the insular tumor was confined lateral to (Group I) or extended medially around (Group II) the lenticulostriate arteries (LSAs). RESULTS: Twenty-five patients (66%) had tumors situated lateral to the LSAs and 13 (34%) had tumors encasing the LSAs. Insular gliomas situated lateral to the LSAs led to significant medial displacement of these vessels (161 +/- 39%). In 20 (80%) of these 25 cases the boundaries between tumor and brain parenchyma were well demarcated on preoperative T2-weighted MR images. In contrast, there was less displacement of the LSAs (130 +/- 14%) in patients with insular gliomas extending around the LSAs on angiography. In 11 (85%) of these 13 cases, the tumor boundaries were diffuse on T2-weighted MR images. Postoperative hemiparesis or worsening of a preexisting hemiparesis, secondary to LSA compromise, occurred in 5 patients, all of whom had tumor volumes that extended medial to the LSAs. Gross-total or near-total resection was achieved more frequently in cases in which the insular glioma remained lateral to the LSAs (84 vs 54%). CONCLUSIONS: Insular gliomas with an MR imaging-defined tumor volume located lateral to the LSAs on stereotactic angiography displace the LSAs medially by expanding the insula, have well-demarcated tumor boundaries on MR images, and can be completely resected with minimal neurological morbidity. In contrast, insular tumors that appear to surround the LSAs do not displace these vessels medially, are poorly demarcated from normal brain parenchyma on MR images, and are associated with higher rates of neurological morbidity if aggressive resection is pursued. Preoperative identification of these anatomical growth patterns can be of value in planning resection

Anteriorly located Type IV thoracic arteriovenous malformations (AVMs) are difficult to treat surgically. Although high-flow fistula subtypes are amenable to treatment using endovascular techniques, low-flow fistulas should be treated surgically. There are few reports discussing the diagnosis, behavior, and treatment of these spinal fistulas due to their low incidence. Posterior surgical approaches to Type IV spinal AVMs reported in the literature have been associated with high morbidity rates or aborted procedures. The authors report the successful management of a T-12 Type IV spinal AVM with an emphasis on approach, interoperative angiography, and the use of modern instrumentation. To the authors' knowledge, this is also the first reported case of multiple arterial-side aneurysms in a Type IV AVM of the anterior spinal artery

The authors report on a case of a patient who received recombinant human bone morphogenetic protein-2 (rhBMP-2) to augment spinal fusion for the first and third of 3 lumbosacral fusion surgeries. After receiving rhBMP-2 the first time, the patient became febrile and developed mild acute renal insufficiency and transient supraventricular tachycardia (SVT). The second operation was complicated only by perioperative fever. When the patient received rhBMP-2 again during the third operation, he developed fever, acute oliguric renal insufficiency, symptomatic SVT with hypoxemia, confusion, and joint pain. No clear cause of these problems was identified; however serum analysis revealed the presence of an antibody to rhBMP-2. The authors discuss potential mechanisms for the patient's putative reaction to rhBMP-2, as the findings from a literature review suggest this is the first such reaction to be reported

OBJECTIVE: To describe the surgical approaches, the radiographic and clinical outcomes, and the long-term follow-up of patients harboring thalamic pilocytic astrocytomas after radical resection by means of a stereotactic volumetric technique. METHODS: Seventy-two patients with thalamic pilocytic astrocytomas underwent stereotactic volumetric resection by the senior author (PJK) at the Mayo Clinic between 1984 and 1993 (44 patients) and at New York University Medical Center between 1993 and 2005 (28 patients). Patient demographics, presenting symptoms, surgical approaches, neurological outcomes, pathology, initial postoperative status, and long-term clinical and radiographic follow-up were retrospectively reviewed. RESULTS: On preoperative neurological examinations, 54 of the 72 patients had neurological deficits; of these, 48 had hemiparesis. Postoperative imaging demonstrated gross total resection in 58 patients and minimal (<6 mm) residual tumor in 13 patients. Tumor resection was aborted in one patient. On immediate postoperative examination, 16 patients had significant improvements in hemiparesis. Six patients had worsening of a preexisting hemiparesis and one had a new transient postoperative hemiparesis. There was one postoperative death. After 13 to 20 years of follow-up in the Mayo group (mean, 15 +/- 3 yr) and 1 to 13 years of follow-up in the New York University group (mean, 8 +/- 3 yr), 67 patients were recurrence/progression-free, one had tumor recurrence, and three had progression of residual tumor. There were two shunt-related deaths. On long-term neurological follow-up, 27 patients had significant improvements in hemiparesis; one patient with a postoperative worsening of a preexisting hemiparesis remained unchanged. There were no patients with new long-term motor deficits after stereotactic resection. CONCLUSION: Gross total removal of thalamic pilocytic astrocytomas with low morbidity and mortality can be achieved by computer-assisted stereotactic volumetric resection techniques. Gross total resection of these lesions confers a favorable long-term prognosis without adjuvant chemotherapy and/or radiation therapy and leads to the improvement of neurological deficits

Electrical stimulation of left temporo-parieto-occipital (TPO) cortex in adult male Wistar rats during their behaviorally active phase (nighttime) transiently increased circulating levels of CD4+ and CD8+ T lymphocytes. Comparable stimulation of this cortex on the right decreased circulating levels of these cells. Responses to left or right cortical stimulation were diminished or absent in behaviorally inactive rats (daytime). Since blood glucocorticoid levels were similar before and after left or right stimulation, they did not appear to account for the lateralized changes observed. These lateralized effects were mediated by spinal cord autonomic pathways emerging at Tl-T7 levels. In adult thymectomized rats, CD4+ and CD8+ T cells failed to increase after left sided stimulation. The results suggest that lateralized cerebral cortical functions can acutely and differentially influence blood T cell subset numbers. The results demonstrate a direct neocortical influence on thymic export of mature T cells, mediated by the sympathetic nervous system.

OBJECTIVE: To look for correlations between acridine orange (AO) staining and semen parameters before and after sperm separation procedures and to assess whether the AO test predicts fertilization or pregnancy outcomes after standard IVF and intracytoplasmic sperm injection. DESIGN: Prospective study that simultaneously assesses sperm morphology and nuclear protein maturity on a cell-by-cell basis before and after preparative procedures. SETTING: University teaching hospital. PATIENT(S): Men (n = 140) undergoing diagnostic semen analysis. MAIN OUTCOME MEASURE(S): Acridine orange fluorescence of sperm nuclei, semen parameters, IVF outcome. RESULT(S): In unprocessed samples, 90% of sperm with normal heads displayed green fluorescence (mature nuclear protein); significantly lower percentages of green fluorescence were observed in sperm with abnormal heads. The percentage of mature normal sperm in the specimen correlated with motility. Sperm maturity after swim-up or Percoll gradient was significantly improved for sperm with normal or abnormal heads. The percentage of mature normal sperm correlated with motility after either Percoll or swim-up. Neither the percentages of mature nuclei nor mature normal nuclei correlated with fertilization or pregnancy outcome. CONCLUSION(S): Nuclear protein maturation correlates with sperm motility and morphology. Because morphologically normal and motile sperm are more mature, separation procedures should generate a population of sperm with the highest fertilization capacity. Acridine orange staining, however, did not predict fertilization efficiency or pregnancy outcome in IVF cycles