Faculty Bibliography

OBJECTIVE:Granular cell tumors (GCTs), pituicytomas, and spindle cell oncocytomas are rare, nonfunctioning pituitary tumors sharing positive staining of thyroid transcription factor 1. We present our series, the first single-institutional report with long-term surgical follow-up of all 3 tumor types. METHODS:Our institutional pathology database was queried for these 3 pathologic diagnoses. Clinical records were assessed for clinical presentation, preoperative and postoperative endocrine status, tumor location on imaging, surgical characteristics, pathology results, and tumor recurrence. RESULTS:Data were analyzed for 4 patients with GCTs, 4 with pituicytomas, and 3 with spindle cell oncocytomas. The most common symptoms at presentation were vision changes (64%), headache (55%), endocrine abnormalities (55%), and fatigue (46%). GCTs were the only subtype to present exclusively in the infundibulum and the only subtype in our series to be treated with a transcranial transsylvian approach to resection (n = 2). In our study, in contrast to other reports, estimated blood loss was less than 300 mL in all patients. Imaging confirmed gross total resection in all 11 cases with no known recurrences at a mean (standard deviation) follow-up of 4.7 (3.7) years. CONCLUSIONS:We present a single-institution series of rare thyroid transcription factor 1-staining posterior pituitary tumors of the sellar region. Key novel findings include gross total resection with no tumor recurrence at nearly 5 years of mean follow-up and no cases of excess or uncontrolled blood loss. Our findings reinforce the observation that GCTs present in the suprasellar space.

OBJECTIVE:Hemorrhagic complications reported from external ventricular drain (EVD) placement range from 10% to 44%. There remains limited literature investigating the incidence, risk factors, and mechanisms to prevent its occurrence, especially in the setting of antiplatelet agent use. We investigated EVD-related hemorrhagic complications after the implementation of VerifyNow platelet inhibition assays at our institution. METHODS:Medical records from 445 patients requiring EVD placement during a 2-year period during which our institution used the assays were reviewed. In total 345 patients were included, and 208 of them underwent assay testing. Indications for EVD included complications of cerebrovascular disease (n = 215), traumatic brain injury (n = 74), primary hydrocephalus (n = 23), and tumor (n = 33). Hemorrhage was defined as any new area of hyperdensity adjacent to or immediately along the catheter trajectory on computed tomography. RESULTS:There was no significant decrease in catheter-induced hemorrhage (CIH) between patients who underwent the VerifyNow assay and those who did not. Platelet transfusion did not significantly decrease the risk of CIH. CIH occurred in 17.7% of patients, significantly decreased when compared with our previously published incidence of 33% before platelet inhibition assay use (P < 0.05). Patients with cerebrovascular disease complications exhibited a significant decrease in CIH, 20% versus 39%, before assay use (P < 0.01). CONCLUSIONS:The incidence of hemorrhage is lower in our new cohort when compared with that of our previously published cohort. Despite the overall decreased rate of hemorrhage, there was no significant difference in hemorrhage rates between patients who did or did not undergo the assay. Platelet transfusion did not decrease the incidence of hemorrhage in patients with inhibited platelet function.

Cavernous malformations of the thalamus represent a particularly complex subset of cavernous malformations because of the highly eloquent nature of the involved tissue and their deep location. The decision about whether to operate on any individual lesion depends on the specific location of the lesion within the thalamus, the nature of the patient's symptoms, and the patient's history. When surgery is recommended, the approach must be chosen carefully. Each part of the thalamus is reached by a different surgical approach. These approaches include the orbitozygomatic approach to the anteroinferior thalamus, the anterior interhemispheric transcallosal approach to the medial thalamus, the anterior contralateral interhemispheric transcallosal approach to the lateral thalamus, the posterior interhemispheric transcallosal approach to the posterosuperior thalamus, the parieto-occipital transventricular approach to the lateral posteroinferior thalamus, and the suboccipital supracerebellar infratentorial/transtentorial approach to the medial posteroinferior thalamus. Careful attention to safe entry zones and image guidance can allow safe removal of these lesions when necessary.

Cavernous malformations are vascular lesions that occur throughout the central nervous system, most commonly in the supratentorial location, with brainstem and cerebellar cavernous malformations occurring more rarely. Cavernous malformations are associated with developmental venous anomalies that occur sporadically or in familial form. Patients with a cavernous malformation can present with headaches, seizures, sensorimotor disturbances, or focal neurologic deficits based on the anatomic location of the lesion. Patients with infratentorial lesions present more commonly with a focal neurologic deficit. Cavernous malformations are increasingly discovered incidentally due to the increasing use of magnetic resonance imaging. Understanding the natural history of these lesions is essential to their management. Observation and surgical resection are both reasonable options in the treatment of patients with these lesions. The clinical presentation of the patient, the location of the lesion, and the surgical risk assessment all play critical roles in management decision-making.

Schizophrenia is a chronic and progressive psychiatric disease that remains difficult to manage in the 21st century. Current medical therapies have been able to give reprieve and decrease incidence of psychotic episodes. However, as the disease progresses, patients can become ever more refractory to current pharmaceutical agents and the polypharmacy that is attempted in treatment. Additionally, many of these drugs have significant adverse effects, leaving the practitioner in a difficult predicament for treating these patients. The history of neurosurgery for schizophrenia, among other psychiatric diseases, has a very dark past. Therefore, this review examines peer-reviewed studies on the history of schizophrenia, its medical and surgical therapies, financial costs, and future directions for disease management. We highlight the historically poor relationship between neurosurgery and psychiatric disease and discuss current research in the understandings of schizophrenia. Guided by a strong code of ethics and new technology, including the use of stereotaxis and deep brain stimulation (DBS), the medical communities treating psychiatric disease are beginning to overcome the horrors of the past. DBS is currently being used with moderate success in the treatment of depression, obsessive compulsive disorder, Tourette's syndrome, and anorexia nervosa. With greater understanding of the neural circuitry of schizophrenia and the evolving role for DBS in psychiatric disease, the authors believe that schizophrenia, like other psychiatric diseases, can be treated with DBS.

This review was focused on understanding which substances inside the human body increase and decrease with increasing neuropathic pain. We reviewed various studies, and saw correlations between neuropathic pain and components of the immune system (this system defends the body against diseases and infections). Our findings will especially be useful for understanding ways to reduce or eliminate the discomfort, chronic neuropathic pain brings with it. Spinal cord stimulation (SCS) procedure is one of the few fairly efficient remedial treatments for pain. A follow-up study will apply our findings from this review to SCS, in order to understand the mechanism, and further optimize efficaciousness.