Subject: Pediatrics
Title: Medulloblastoma in a child with Curry-Jones Syndrome: A Case Report
Authors: Jeremy Phelps; Paul T. Turner; Howard Yonas
Introduction: Curry-Jones syndrome is a dysmorphic condition first described in 1987(Cohen, 1988). Subsequent articles (Temple, 1995; Thomas, 2006) have reported multiple cases of this condition, but the total number of individuals isolated to date remains small. The syndrome consists of a constellation of congenital abnormalities, each demonstrating pre-axial polydactyly and syndactyly of the hands and feet, as well as characteristic skin changes consisting of pale atrophic areas of scarring in a linear distribution which are commonly associated with increased hair growth. Other common features include anterior plagiocephaly, hypertelorism, a flat nasal bridge, narrow palpebral fissures, a flat philtrum, a ìcarp-shapedî mouth, and absence or partial absence of the corpus callosum. Cerebral cysts, abnormal gyri formation, asymmetric ventricular size and malrotation of the gut leading to intestinal obstruction have also been reported. The majority of patients exhibit developmental delay or mild mental retardation.
Methods: History and Examination: The two-year-old male was a full-term product of non-consanguineous relationship. The pregnancy was complicated by diet-controlled gestational diabetes. There were no known teratogenic exposures. On examination as an infant, the patient had mild hypertelorism, a flat nasal bridge and philtrum, a 4x5x4cm occipital meningocele. He demonstrated pre-axial polydactyly on the right hand and bilateral feet. Syndactyly of the second and third digits of the right hand, fourth and fifth digits of the left hand, and third and fourth digits of the feet was present. He also demonstrated multiple hypo-pigmented patches over the left groin area. An MRI demonstrated an enlarged left lateral ventricle, hypogenesis of the splenium of the corpus callosum, and an occipital meningocele. The occipital meningocele was resected within the first month of life. The patient tolerated the surgery without complication. A six month follow-up MRI demonstrated a 3x3x3 cm intraventricular, homogeneously enhancing mass filling approximately 80% of the fourth ventricle (Figure 2). Imaging of the spinal axis was negative.
Results: Treatment: The patient underwent mass resection. Surgical pathology confirmed the diagnosis of desmoplastic medulloblastoma (WHO grade 4/4). He received chemotherapy course consisting of the COG protocol 9934 (cisplatin, cyclophosphamide, VP 16 and vincristine.) A subsequent course of adjuvant radiation therapy (5040 cGy to tumor site and 1800 cGy to the posterior fossa) was also completed.
Conclusions: Associations between medulloblastomas and Curry-Jones syndrome have not been previously reported. Medulloblastomas are common malignant pediatric brain tumor accounting for approximately 20%-25% of all pediatric brain tumors. Genetic abnormalities associated with medulloblastomas include alterations in chromosome 1, duplications of chromosome1q or chromosome 7, loss of chromosome 22 or chromosome 17p(Binger, 1997). Two genetic syndromes, nevoid basal cell carcinoma (Gorlinís syndrome) and multiple colonic polyposis (Turcotís syndrome) have also been associated with medullaoblastoma (Evans, 1991; Lacombe, 1990). The genetic defect of Curry-Jones syndrome has yet to be elucidated. While no definitive genetic link has been made between Curry-Jones syndrome and medulloblastoma, the association of gut abnormalities with each condition is intriguing. Elucidation of the genetic abnormalities of Curry-Jones syndrome may allow additional correlations to be made.
Keywords: Curry-Jones syndrome, medulloblastoma, pediatric neurosurgery
Objectives: Following this presentation, participants should be able to (1)describe the key features of Curry-Jones syndrome and (2)describe the neurosurgical diseases which have been reported in relationship to this condition.
Subject: Tumor
Title: The role of Alcohol Cauterization in the Surgical Treatment of Rathkeís Cleft Cysts ñ review of a large clinical series.
Authors: Kevin O Lillehei; Lars Widdel; Carolina A Arias-Astete; Bette K Kleinschmidt-Demasters; Margaret Wierman; Janice Kerr
Introduction: Rathkeís Cleft cysts (RCC) are believed to represent a continuum of epithelial lined cystic lesions, ranging from a simple epithelial (arachnoid) cyst, to RCC, to craniopharyngioma. Treatment of these lesions continues to be complex with a fraction of patients developing recurrence. In this study we evaluate factors influencing outcome in treatment with symptomatic Rathkeís cleft cyst (RCC).
Methods: A retrospective review of 98 out of 1000 patients with sellar lesions treated by a single neurosurgeon was performed. We evaluated their epidemiology, presenting clinical findings, surgical and adjuvant treatments, pathological findings, recurrence and outcomes.
Results: Patients with RCC- average age of 34 (range 10-90) ñ presented mainly with headache (68.1%) or visual symptoms (38.5%), while endocrinopathy was noticed in lesser frequency. Follow-up averaged 40 months (1 month to 25 years) 108 surgeries were performed with an overall recurrence of 10.2% while the recurrence rate for the newly diagnosed RCC was 8.8%. Recurrence was statistically significant for RCC with squamous metaplasia, but not for intra-operative ethanol application or clinical presenting symptoms.
Conclusions: Trans-phenoidal surgery remains the mainstay of treatment for symptomatic RCCs with good clinical results and minimal complications if overly aggressive maneuvers are avoided. Presence of squamous metaplasia should warrant closer follow-up due to higher recurrence rates. Intraoperative alcohol cauterization does not appear to be beneficial
Keywords: Rathke’s cleft cyst, alcohol cauterization, squamous metaplasia
Objectives: 1.- Identify epidemiological and clinical presentations of patients with Rathke’s cleft cyst 2.- Identify factors influencing surgical outcome and complications 3.- Identify factors related to recurrence of disease.
Subject: Tumor
Title: Rathkeís cleft cyst and adenomas ñ a uncommon combination
Authors: Lars Widdel; Kevin O Lillehei; Glenn Kindt; Carolina A Arias-Astete; Bette K Kleinschmidt-Demasters
Introduction: Rathkeís cleft cysts (RCC) and pituitary adenomas have common embryologic origin. Both lesions are described to be present by themselves in 10-33% of the population; however they are rarely encountered in combination.
Methods: We performed a retrospective review on all patients treated for combined RCC and pituitary adenomas at out institution to evaluate their epidemiological and clinical features and their outcome after therapy.
Results: 12/1000 patients with surgically treated sellar lesions were found to have both RCC and pituitary adenomas. It was more common in women (10) of middle age (average 41.5 years of age). 58% presented with an endocrinopathy while the rest had only symptoms due to mass effect. Only in 25% was the combination both lesions identified on pre-operative imaging. Most adenomas were non-secreters, although lactotroph, somatotroph and corticotroph adenomas were found. All patients had good surgical outcome without recurrence.
Conclusions: The combination of RCC and pituitary adenomas is overall rare, although occasionally symptomatic. Surgical therapy continues being the mainstay in treatment with good outcomes.
Keywords: Rathke’s cleft cyst, pituitary adenoma,
Objectives: 1.- Discuss the prevalence of Rathke cledft cysts and pituitary adenomas 2.- Discuss presenting symptoms of this entity 2.- Discuss treatment options and outcomes.
Subject: Pediatrics
Title: Iatrogenic Epidermoid Cyst Following Placement of an Intracranial Pressure Monitor
Authors: Erika A Petersen; Frederick Sklar
Introduction: Epidermoid inclusion cysts are a known complication following trauma or surgery. There are a few reports of intracranial epidermoid cysts following penetrating trauma, most occurring several years after the suspected inciting event. To our knowledge, this is the first case of an iatrogenic epidermoid cyst developing within a few months following the insertion of an intracranial pressure monitor.
Methods: A previously healthy four year-old boy suffered a closed head injury and extremity fractures in a high speed motor vehicle collision. A CT scan suggested bifrontal diffuse axonal injury without focal hemorrhage. A Codman Microsensor intraparenchymal intracranial pressure (ICP) monitor was placed in the right frontal region, and ICPs were managed medically for seven days. The patientís neurological status improved, and the monitor was removed. Facial edema and subcutaneous fluid in the right frontal region that were present on admission resolved with time. The ICP monitor insertion site healed well, and the boy recovered to baseline function with rehabilitation. Within four months there developed a right frontal raised subcutaneous mass measuring 25 x 20 x 7 mm, which was firm, rubbery, and nontender. CT scan demonstrated a well-defined oval non-lobulated discrete lesion of fat density in the right frontal subgaleal space. MRI showed a peripherally-enhancing subgaleal collection that appeared hypointense on T1 and moderately hyperintense on T2 weighted images. No intracranial abnormality was appreciated.
Results: A small right frontal craniotomy was performed for resection of the lesion. The subgaleal waxy deposits were found to extend within the prior burr hole and into the subdural space. There was no pial involvement. The cyst appeared to have ruptured, and thickened pericranium tracked to the forehead. This thickened tissue and additional encapsulated keratinous material was removed. Pathological evaluation of the resected specimen demonstrated keratinous debris with a foreign body giant cell reaction, suggestive of a ruptured epidermoid cyst. There was no epithelium suggestive of capsule identified. The boy recovered well and has had no evidence of recurrence of the lesion at one year.
Conclusions: There are only a few instances of cranial acquired inclusion cysts reported in the literature, and many of these develop decades after the traumatic event. Spinal epidermoid cysts are a known possible complication of lumbar puncture, occurring most often when the procedure is performed with a hollow needle and no stylet. These cysts develop between two and twenty years after the procedure. The exact etiology of this patientís epidermoid cyst is not clear, but its development may be related to the introduction of epidermal tissue from the skin incision or the puncture site of the Tuohy needle during placement of the ICP monitor. This case is also notable for the rapid increase in size of the lesion over the course of a few months and the cyst rupture which caused extension over the forehead.
Keywords: Trauma, Acquired epidermoid cyst, intracranial pressure monitoring
Objectives: 1) Review the etiologies of acquired cranial epidermoid cysts 2) Describe the epidemiology of iatrogenic epidermoid cysts in the CNS 3) Review the radiographic and pathologic characteristics of an epidermoid
Subject: Socioeconomic
Title: Resident Innovation: Encouraging creativity and removing barriers
Authors: Jeremy Phelps; Shawn Carraher; Douglas E. Thomas; Hoan P. Tran
Introduction: Neurosurgeon innovation has long been an integral part of the modernization of healthcare. Appuzo et al. (2009) assert that creativity and innovation are essential elements in the modernization of neurosurgery. Furthermore, they feel that these forces will serve to vitalize and energize the specialty. Given the historical participation of neurosurgeons in innovation and the burgeoning of technology (Muraszko, 2003), one would assume that neurosurgeon innovation is flourishing, especially for younger surgeons facile with both technology and the specialty. In-training physicians (residents) can play a significant role in innovation as practitioners at the ìgrass rootsî level (Gravel et.al. 2009). While neurosurgeons continue to push the bounds of technology and its application, multiple barriers to innovation remain. Although the literature on neurosurgical innovation is increasing, little exists concerning resident-specific barriers to innovation. This paper seeks to clarify resident-specific barriers to innovation and methods to overcome the barriers in order to foster innovation with a new generation of neurosurgeons.
Methods: A literature search was performed utilizing PubMed, BioMed, and Business Source Premier utilizing the terms ìneurosurgeryî, ìinnovationî, ìresidentî, and ìresidencyî. Results were reviewed and limited to articles directly discussing resident involvement in the innovation process. Articles outside of the specialty of neurosurgery were also reviewed to achieve a broader assessment of the topic under consideration.
Results: Although several articles deal directly with barriers to innovation (Fleuren et al., 2004; Phelps and Carraher, 2009), few specifically mention resident-driven innovation. Following a review of the available literature, several individual factors limiting resident-driven innovation were delineated. These were grouped into four broad categories: inadequate experience, inadequate contacts, insufficient time, and miscellaneous (Table 1). The reviewed articles provided several methods for fostering resident-driven creativity and innovation. Additionally, several other means for encouraging innovation were added by the authors (Table 2).
Conclusions: Creativity and innovation are necessary if neurosurgery is to continue to provide cutting-edge patient care. Residents are in an ideal position to understand the current challenges of care delivery and technology essential to fostering ideas that may lead to improved techniques, systems, and patient care. However, they often encounter barriers specific to their position which hinder or even prevent them from bringing forth new innovations. Understanding these specific impediments is the first step to overcoming potential difficulties. Implementation of specific approaches, while no guarantee of success, may assist resident physicians in overcoming these barriers and increasing their involvement in the innovation process.
Keywords: Resident, innovation, barriers, research
Objectives: At the completion of this session, participants should be able to 1) identify the key reasons that resident physicians should be involved in the innovation process, 2) identify current barriers that residents face in this process, and 3) discuss possible methods to encourage resident innovation.
Subject: Functional
Title: Image-Guided Frameless Stereotactic Targeting Of The Subthalamic Nucleus Without Microelectrode Recording: Post-Mortem Neuropathological Analysis
Authors: Erika A Petersen; Etienne Holl; Alek Pogosyan; Thomas Foltynie; Luke A Massey; Patricia Limousin; Marwan Hariz; Peter Brown; Janice Holton; Ludvic U Zrinzo
Introduction: This report presents the first post-mortem study providing pathologic verification of deep brain electrode location following frameless stereotactic implantation using intraoperative local field potential measurements.
Methods: Subthalamic (STN) deep brain stimulation (DBS) was performed on a sixty-seven year-old gentleman with a sixteen-year history of idiopathic Parkinsonís disease (PD) with increasing off time and worsening gait. Because frame-based surgery was not technically possible, the operation was performed using frameless guidance. The surgical technique emphasized an image-directed approach and was supplemented by intraoperative macrostimulation and local field potential (LFP) measurements but not by microelectrode recording (MER).
Results: Intraoperative LFPs suggested that the electrode was outside the beta generator on the left (no beta frequency band activity peak) and was closer on the right (small peak). Postoperative MR imaging documented electrode placement within the subthalamic area bilaterally. The left electrode was 2 mm medial to the STN within the Zona Incerta and the right electrode was within the medial STN. With stimulation the patient demonstrated improvements in bradykinesia and rigidity; however, in the following months, his general condition deteriorated due to rapidly progressing metastatic adenocarcinoma. The patient died eleven months after electrode implantation and the brain was donated for postmortem study. Neuropathological examination confirmed the diagnosis of Parkinsonís disease and ascertained the electrode positions in the subthalamic area bilaterally. There was evidence of mild gliosis and hemosiderin staining along the electrode tracks without evidence of focal tissue damage. The location of the electrode artifacts on postoperative MRI correlated closely with postmortem findings. The small peak in beta frequency band activity during intraoperative LFP recording from the right electrode and the absence of beta activity from the left electrode corresponded with the electrode positions relative to the STN in the brain specimen.
Conclusions: Satisfactory placement of electrodes may be achieved by precise anatomical targeting without MER guidance. LFP recordings may provide alternative electrophysiological confirmation of electrode placement within the STN. Although the authors advocate a frame-based approach where possible, a frameless approach appeared to be sufficient in this instance
Keywords: deep brain stimulation, post-mortem, local field potentials
Objectives: 1) Describe several methods for defining a DBS target for PD 2) Weigh the risks and benefits of various electrophysiological techniques for STN localization 3) Appreciate the neuroanatomy of the target region for DBS
Subject: Spine
Title: Capanna’s Spider Sign
Authors: Albert H. Capanna; Dawn M. Capanna
Introduction: Capanna’s Spider Sign was noted to be present on magnetic resonance (MR), computerized tomography (CT), and myelographic CT scans in patients with lumbar pathology and some low thoracic lesions. If the sign is present and the study is interpreted as normal- further work up with an additional study is indicated to completely rule out pathology. Patients whoís radiologic studies are interpreted as ìnormalî who have the spider sign should be further evaluated as they likely do have pathological lesions which may be surgically corrected.
Methods: Capanna’s Spider Sign is seen on the transverse sections of MR, CT, and myelographic CT scans at the location of the conus medularis and the beginning of the filum terminale. Its presence is distinctive and easily recognized. For two years, all patients seen in clinic for lumbar pathology or to rule out lumbar pathology had their imaging studies reviewed for the presence or absence of the spider sign. It the spider sign was present and no pathology was noted, further imaging studies were done.
Results: The results of all the patients will be presented showing radiographic examples. It is felt that the spider sign arises because of pressure on the filum terminale or cauda equina nerve roots. This decreases the pressure on the conus medularis, and relaxed nerves at the conus level. The relaxed conus and nerve roots imparts the appearance of a spider on transectional views.
Conclusions: Capanna’s Spider Sign is a helpful diagnostic sign. Its absence should lead the prudent spinal surgeon be cautious about any surgical procedure on the patient. The Spider Sign’s presence should signal caution when dismissing a patient as having no surgical pathology and if present should lead to further testing before concluding that the patient has no pathology.
Keywords: Spine, Diagnostic Sign, MR, CT/myelogram
Objectives: Recognize Capanna’s Spider Sign. Have further confidence to order or not order additional imaging studies in a patient. Have an additional sign to help the difficult to diagnose patient.
Subject: Tumor
Title: Overall survival, tumor control, visual and endocrine outcomes for patients treated with intensity modulated radiosurgery for parasellar lesions.
Authors: Randy L. Jensen; Dennis C Shrieve
Introduction: Parasellar lesions can be treated with either single fraction radiosurgery (SRS) or fractionated stereotactic radiotherapy (FSRT). Our preference is to treat these lesions with SRS when feasible. Linear accelerator SRS is usually delivered with dynamic conformal arcs (DCA) but intensity modulated radiosurgery (IMRS) is another option when SRS dose is limited by proximity of the optic nerve and chiasm.
Methods: We describe our methods and results of IMRS for patients with parasellar lesions that we wished to treat with SRS but were concerned that dose to the optic nerve or chiasm might exceed our acceptable dose tolerances (8 Gy). Sixteen patients with parasellar lesions that appeared to be more than 4 mm from the optic nerve and chiasm on standard MR imaging but were thought to be questionable candidates for radiosurgery due to concerns of dose to optic nerve or chiasm were considered for IMRS. Preprocedure plans were performed and analyzed. Both DCA plans for SRS and IMRS plans were evaluated. Dose to the prescribed tumor volume (PTV) and organ at risk (OAR) were assessed by dose-volume histograms, homogeneity index and conformality index (CI) calculated to characterize the quality of the different plans. Marginal doses were 15 to 20 Gy (median 15 Gy) to prescription isodose line of 80-100% (median 97%) delivered by 8-22 fields. Long-term endocrine function, detailed opthalmological exam, tumor control, and patient survival were assessed.
Results: Eight patients have cavernous sinus meningiomas and 8 patients have pituitary tumors (5 nonsecreting, 2 ACTH secreting, 1 GH secreting). Fifteen of 16 patients are alive with follow-up of 14.9 to 96.86 months (median 42.43 months). One patient died of breast cancer unrelated to the treated lesion. Fifteen of 16 tumors are stable without radiographic or hormone tumor progression. One patient had progression of her ACTH secreting pituitary adenoma 2 years after treatment requiring repeat surgery and fractionated radiotherapy. In most cases the DCA plan precluded delivery of therapeutic dose without exceeding optic tolerance. IMRS allowed maximum doses of 20 to 31 Gy using the same optic apparatus dose restriction. There have been no opthalamologic or endocrine complications to date.
Conclusions: IMRS can be used to deliver radiosurgery treatment to lesions near the optic apparatus when standard DCA SRS is not feasible. IMRS for parasellar lesions appears to be an effective and safe treatment option.
Keywords: stereotactic radiosurgery, optic neuropathy, endocrinopathy, intensity modulated radiation
Objectives: 1. Understand limitations for radiosurgical treatment of parasellar lesions 2. Compare differences between dynamic conformal arc radiosurgery and intensity modulated radiosurgery 3. Describe the use of intensity modulated radiosurgery to reduce optic neuropathy
Subject: Cerebrovascular
Title: Stenting for Extracranial and Intracranial Carotid and Vertebral Traumatic Dissections and Pseudoaneurysms: Review of the Literature and Case Presentations
Authors: Ted Larson
Introduction: Traumatic injuries to extracranial and intracranial carotid and vertebral arteries are commonly encountered lesions at trauma centers. These can be asymptomatic or cause stroke or hemorrhage. Common treatment strategies are divided into anticoagulation or antiplatelet medication based on lesion grade. Stenting with or without coils have been suggested as endovascular treatment options in certain circumstances.
Methods: Literature review of endovascular treatment of extracranial and intracranial carotid and vertebral traumatic dissections, transections, and pseudoaneurysms was performed. Spontaneous, iatrogenic, and traumatic penetrating dissections and fistulas were excluded. Personal cases were retrieved from archival storage.
Results: Limited case studies or small series of stent treatment with or without coils were available in the English literature. Stents employed were covered or open cell. Occasional reports of embolic protection devices were available. Decision to treat was based on physician judgement. Select examples of various scenarios leading to endovascular treatment will be presented illustrating high grade stenoses, progressive stenoses, enlarging pseudoaneurysms, imaging documentation of diminished cerebral perfusion, or symptomatic lesions while on medication.
Conclusions: Endovascular treatment using stents with or without coils can be employed to treat traumatic extracranial or intracranial carotid or vertebral artery dissections and pseudoaneurysms with a low complication rate. Guidelines may be used to select patients for endovascular treatment. A small randomized controlled trial would add credibility to this treatment paradigm.
Keywords: Stents; Cervical/Cerebral Vascular Trauma
Objectives: 1. Recognize the appearance of extracranial and intracranial carotid and vertebral artery traumatic dissections and pseudoaneuryms. 2. Become knowledgeable about lesion grading and standard medication regiments to treat these cervical and cerebral vascular lesions. 3. Have an understanding of the medical literature describing the endovascular treatment of dissections or pseudoaneurysms of the internal carotid and vertebral arteries.
Subject: Tumor
Title: Antiangiogenesis therapy for malignant gliomas: A review for the practicing neurosurgeon
Authors: Randy L. Jensen
Introduction: One of the phenotypical changes found in glioblastoma multiforme (GBM) is the highly vascular nature of these tumors. Angiogenesis has long been thought an important step in the progression of low grade to higher grade gliomas. Thus antiangiogenesis therapy is an appealing method of treatment for these tumors
Methods: I will discuss the pathophysiology of glioma angiogenesis with focus on the hypoxia-regulated transciption factor Hypoxia-Inducible Factor-1 (HIF-1) and its downstream regulated protein Vascular Endothelial Growth Factor (VEGF). Current trials involving anti-VEGF therapy will be discussed including the recent Federal Drug Adminstration (FDA) approval of the anti-VEGF drug Bevacizumab (Avastin).
Results: Implications of the use of this drug as ìstate of the artî for GBM will be discussed. Potential pitfalls of antiangiogenesis therapy as well as the anti-edema side effects of these agents will be explored. New emerging anti-angiogenesis therapies and other targets will also be highlighted.
Conclusions: Although, alone antiangiogeneis therapy is no a durable treatment option, combination therapy with anti-neoplastic agents has proven effective in the treatment of GBM. Antiangiogenesis therapy will be a mainstay in the treatment regimens of future GBM clinical trials.
Keywords: VEGF, HIF-1, Avastin, Bevacizumab
Objectives: 1. Understand the pathophysiology of brain tumor angiogenesis 2. Describe various anti-angiogenesis therapies available for GBM 3. Discuss the appropriate use of angiogenesis therapy for GBM
Subject: Socioeconomic
Title: Preliminary attempts at a program of assessing surgical competency and enhancing neurosurgical resident training.
Authors: Randy L. Jensen
Introduction: Those providing training in procedural medical specialties face a dilemma in how to provide adequate training within the current medical and legal climate. Surgical training programs are limited in their ability to train residents in the operating room because of limited-hour work weeks, financial constraints including the increasing demand for operating room productivity, ethical concerns, federal regulation of attending surgeon participation, and the general public awareness of medical errors. As teaching hospitals become increasingly financially strained, in may not be feasible to use the operating room as a venue for learning new skills. Clearly any educational experience that can improve the efficiency of the training process would be welcome
Methods: Competency in surgery requires the acquisition of a certain degree of factual knowledge, clinical judgement, interpersonal communication capability, and technical skills. The established mode of training has been the apprenticeship model first established by William Halsted. This is a time honored but somewhat loosely defined system with the unofficial motto of ìsee one, do one, teach oneî. This model has worked for many years but in the contemporary medical educational environment a more structured training model is desirable. Training can be guided by training time, number of training repetitions, or trainee performance. Control of each variable can produce distinctly different outcomes based on the natural baseline ability of the trainee. If training is based on number of repetitions, a naturally gifted trainee completes the requirement in a relatively short time and performs at a high level, whereas the less gifted trainee takes longer and may still be performing suboptimally. If the training time is static, the gifted trainee generates a high number of repetitions and may grow bored with training before completion while the less gifted trainee completes fewer repetitions in the allotted time and may fail to achieve the performance goal. With this is mind a performance-based endpoint with proficiency-based training strategy is attractive. Proficiency-based programs have been developed for a number of procedures including nonsurgical airway management, laproscopic skills, thoracentesis and proficiency of knot tying and suturing in surgical residents. At present there is no such program in place for neurosurgical skills.
Results: I describe an early attempt to develop a program with: 1. Metrics to assess competency of ìkeyî cases for given level of training, 2. A proficiency-driven curriculum for each ìkeyî case, 3. Examines the variations among trainees in time to achieve competency for a specific procedure both and 4. Methods of predicting which students will require more time to master a given procedure and who will never obtain this proficiency.
Conclusions: This is a crude and preliminary idea at a potential curriculum for neurosurgical training. With input from the audience and further work this could be developed into a method that provides neurosurgical resident training in a more formal, streamlined manner. Whether this would subsequently result in a better educational experience for the neurosurgical trainee is yet to be determineded.
Keywords: education, competency, training, resident
Objectives: 1. Understand the current pitfalls of neurosurgical resident training. 2. Describe how a proficiency-drive curriculum might improve resident training. 3. Discuss how competency can be determined for a given neurosurgical skill.
Subject: Cerebrovascular
Title: Sole Stent Technique for Treatment of Complex Aneurysms
Authors: Young-Joon Kim
Introduction: Treatment for very small aneurysm is also difficult because of tearing or narrowing the parent vessel during clipping in cases of surgical clipping and insufficient saccular space to deploy coil in endovascular cases. Fusiform aneurysm is also difficult and dangerous to be treated by surgical clipping or endovascular coiling because it has fragile wall and indistinct neck. With development of stent material and technique, the new concept has been evolved recently into ìendovascular bypassî or ìendovascular reconstructionî which is enabled to preserve affected parent artery and perforators, and occlude aneurysm safely. The author reports follow-up results of 9 cases treated by sole stent technique, and review the results in other literatures.
Methods: A retrospective study was made of 9 patients who treated by sole stenting technique for cerebral aneurysm between January 2003 and January 2009. There were 5 males and 4 female with mean age of 53.3 years (range from 43 to 67 years), and 5 cases is ruptured and 4 is unruptured state. Fusiform aneurysm was two cases, very small aneurysm (< 3mm) was five, and small aneurysm (>3mm) was two. 7 aneurysms were located in ICA, 1 in middle cerebral artery (MCA) and 1 in basilar artery. Follow-up cerebral angiography was performed at post-procedure 3 months, 6 months and 12 months. Mean follow-up period is 10 months (ranged from 3 days to 30 months).
Results: 8 patients were treated by sole stenting technique and 1 by stent assisted coiling. The latter patients had ruptured very small aneurysm of left ICA. At 3 months after stent assisted coiling, the migration of coil mass into distal MCA was revealed in Follow-up cerebral angiography. Single stenting was performed in 6 cases, double stenting in 2 and tandem stenting was performed in 1. In 6 of 9 cases, aneurysm size was decreased and in 3 cases, was not changed at follow-up image. Although, total occlusion was not seen, all patients have stable neurological condition and angiographic result. The procedural complications occurred in 2 cases. One was coil migration into distal artery and another suboptimal deployment of stent.
Conclusions: Although there are no cases of complete occlusion, 9 patients treated by sole stenting technique have stable clinical state and favorable angiographic result. Sole stenting technique may be relatively effective and safe for alternative treatment of fusiform and very small sized aneurysm. More long-term outcome and analysis should be necessary.
Keywords: Sole stent, Complex aneurysm, Subarachnoid hemorrhage
Objectives: 1) learn how to make the sole stent technique. 2) get the idea on the endovascular treatment of very complex aneurysm. 3) develop the new stent system.
Subject: Socioeconomic
Title: Neurosurgery in North Vietnam
Authors: Andrew S Levy
Introduction: Neurosurgical care is beginning to evolve in North Vietnam, but has had very little support from outside the region.
Methods: A neurosurgeon from a trauma center in Colorado traveled to Hanoi, Vietnam with a group of internists and critical care physicians that have made a number of teaching visits to Vietnam over the last 12 years. Equipment for placement of ventriculostomies was taken to Hanoi, including reusable hand drills, ventriculostomy catheters, and external drainage systems, and techniques for using the equipment was taught to the neursurgeons at two busy hospitals in Hanoi.
Results: Patients with severe traumatic brain injuries (TBI) in North Vietnam are not being managed with intracranial pressure (ICP) monitoring or modern neuro-critical care techniques. Vietnamese physicians at two seperate hospitals in Hanoi were very receptive to learning techniques in ICP monitoring and treatment, and neuro-critical care management for their patients with severe TBI and other neurosurgical disorders. They were also very appreciative of the equipment that was donated to them, but will have a very hard time continuing to provide aggressive TBI management and ICP monitoring without further equipment donation and educational support.
Conclusions: The North Vietnamese medical community is very eager, willing and able to improve the care that they provide to their neurosurgical patients, but much more support in equipment and education is still needed.
Keywords: International Neurosurgery, Mission
Objectives: To understand the neurosurgical condition and needs in North Vietnam.
Subject: Spine
Title: Decorin and GRP-derived Astrocytes: New Technologies for Spinal Cord Repair
Authors: Stephen JA Davies; Jeannette E Davies
Introduction: Scar tissue, myelin associated inhibitors and the loss of axon growth supportive glia are thought to contribute to the ultimate failure of the injured spinal cord to regenerate. My research team is therefore developing two complementary approaches to render the environment of the spinal cord more supportive of axon regeneration and functional recovery after traumatic injury.
Methods: One approach is to promote axon regeneration and/or plasticity by overcoming the inhibitory effects of scar tissue and myelin associated molecules with a small leucine rich proteoglycan called Decorin. The other is to generate specific types of astrocytes from embryonic glial restricted precursors (GRPs) that are suitable for ìbridgingî spinal cord injuries.
Results: Infusion of human decorin into acute rat spinal cord injuries resulted in suppression of inflammation, astrogliosis and multiple inhibitory chondroitin sulfate proteoglycans (CSPGs), changes that supported sensory axon growth across decorin treated injuries. In addition, decorin directly boosts the ability of adult sensory neurons to extend axons by up to ~15 times when grown on inhibitory CSPGs and myelin membranes in vitro. Transplantation of a specific subtype of GRP-derived astrocytes (GDAsBMP) into adult rat spinal cord injuries resulted in robust axon regeneration, neuroprotection of CNS neurons and locomotor recovery. Transplantation of naÔve GRPs or GDAsCNTF (another subtype of GDA) into spinal cord injuries however did not provide any such benefits.
Conclusions: That decorin can both suppress spinal cord scar formation and effectively desensitize adult neurons to the inhibitory effects of scar and myelin associated inhibitors, supports the future use of this molecule in treating both acute and chronic human spinal cord injuries. Pre-differentiation of naÔve stem cells or glial precursors to a specific sub-type of astrocyte is required to promote axon regeneration and functional recovery after traumatic spinal cord injury. GDAsBMP are a novel and highly effective cell type for repairing the injured adult CNS. Decorin and GDAsBMP represent complementary technologies for repairing the traumatically injured adult spinal cord.
Keywords: spinal cord injury, scar tissue, axon growth inhibitors, cell transplantation therapy,
Objectives: 1. Identify factors that inhibit regeneration of the injured spinal cord. 2. Describe the benefits of decorin infusion and GDAsBMP cell transplantation into the injured spinal cord. 3. Understand the importance of pre-differentiation of precursor and stem cells prior to transplantation into injured spinal cord.
Subject: Spine
Title: Transplanted astrocytes derived from BMP or CNTF treated glial restricted precursors have opposite effects on allodynia after spinal cord injury
Authors: Jeannette E Davies; Stephen JA Davies
Introduction: A variety of cell transplantation therapies are being developed for treatment of spinal cord injury. We have recently shown that transplantation of a specific subtype of astrocyte (GDAsBMP), but not its precursor cell or another subtype of astrocyte, into adult rat spinal cord injuries resulted in robust axon regeneration, neuroprotection, and locomotor recovery. A critical challenge in the development of cell based therapies is to identify and prohibit potential adverse side effects. Several recent studies have reported that transplantation of neural stem cells (NSCs) into spinal cord injuries causes pain syndromes. In one published report, this adverse side effect was correlated with the differentiation of transplanted stem cells into astrocytes. Therefore it is very important to determine if transplantation of any astrocyte, or precursor cells capable of generating astrocytes would promote pain syndromes or whether this is a problem unique to the transplantation of NSCs.
Methods: Glial restricted precursors (GRPs) and astrocytes derived from GRPs treated with either BMP (GDAsBMP) or CNTF (GDAsCNTF) were transplanted into acute unilateral drosolateral funiculus transection injuries in adult rats. Animals were tested weekly for the development of thermal hyperalgesia and mechanical allodynia.
Results: Transplantation of GDAsBMP, which promotes robust locomotor recovery, did not cause pain syndromes. In stark contrast, transplantation of naÔve GRPs or GDAsCNTF into spinal cord injuries promoted both thermal and mechanical allodynia. GRP and GDAsCNTF transplantation also resulted in sprouting of calcitonin gene related peptide (CGRP) positive pain fibers, while transplantation of GDAsBMP did not.
Conclusions: Astrocyte transplantation therapy after spinal cord injury can provide substantial benefit if controlled pre-differentiation of embryonic spinal GRP cells to a specific population of astrocytes such as GDAsBMP is conducted prior to transplantation. Pre-differentiation of GRP cells to such astrocytes can also avoid the problem of transplanted glial precursor cells themselves causing pain syndromes like those caused by NSC transplantation to acute spinal cord injuries.
Keywords: neuropathic pain, astrocyte, stem cell, spinal cord injury
Objectives: 1. Understand the importance of pre-differentiation of precursor and stem cells prior to transplantation into injured spinal cord. 2. Identify cell types that promote recovery without inducing pain after transplantation into injured spinal cord. 3. Describe functional assays of thermal or mechanical allodynia in a rodent model of SCI.
Subject: Pediatrics
Title: Television Tipovers: A Continued Public Health Concern And Source Of Significant Pediatric Neurosurgical Morbidity and Mortality
Authors: Kelly Schmidt; Christina M Harrington; Dale Swift
Introduction: Televisions are ubiquitous in the United States. Increasing television screen sizes result in a large increase in anteriorly displaced weight. A relatively small force applied to the front or top of a television set can tip it forward – an effect that is exaggerated when the set resides at a height on a supporting structure that itself may not have adequate stability. Young children have the developing motor skills that allow them to pull up and even climb objects. However, they lack the ability to reflexively avoid falling objects or to cognitively be aware of a dangerous situation. The interaction between a child and an unsecured television set can result in significant morbidity or mortality. Since 1998, a handful of studies describing the phenomenon of television tipovers have been published. Most injuries occur in children under 2 years and involve the head and neck region. We have identified over 70 patients in a nine year period who presented with injuries related to a television tipover. This is almost four times as many as the largest published series in a similar time frame. The purpose of our study is to describe our extensive experience with injuries related to television tipovers with a particular focus on neurosurgical injuries.
Methods: Patients who present to Children’s Medical Center in Dallas, Texas who are evaluated by the trauma surgery team are entered into the National Trauma Registry database which is maintained at our institution by the trauma department. This database was searched for patients who presented between January, 2000 and May, 2009 with injuries sustained secondary to a television tipover. The identified patient charts were then retrospectively reviewed. Collected data included demographics, initial GCS, injuries, radiographic and surgical procedures, admission and discharge neurologic deficits, and discharge disposition. Additionally, patient families were contacted to provide details of the accident such as television size, screen type, the involved supporting structure, accident location, and the circumstances surrounding the tipover.
Results: At the time of this abstract submission, the data is still being fully analyzed. However, it is clear that our institution has the largest series of patients presenting with injuries related to a television tipover of any previously published study. As in prior studies, head and neck injuries predominate – many of which are of neurosurgical significance.
Conclusions: We believe that television tipovers, despite some effort at increasing public awareness after prior published studies, remain a significant public health concern. Parents of young children who can be educated about this home hazard, can take simple steps to prevent a tipover from occurring in their own home. Additionally, our series suggests that television tipovers continue to be a source of significant neurosurgical injury in children. Early recognition and treatment of the sequelae of blunt head and neck trauma in the pediatric population may prevent additional morbidity and mortality.
Keywords: Television, Trauma, Head Injury, Blunt Cerebrovascular Injury
Objectives: 1. Have the ability to increase public awareness about the dangers of unsecured televisions and young children. 2. Describe the neurosurgical injuries often associated with television tipovers. 3. Describe the evaluation and treatment of blunt cerebrovascular injury associated with complex basilar skull fractures in patients with head and neck trauma.
Subject: Socioeconomic
Title: Ethics in an Unethical World
Authors: Albert H. Capanna
Introduction: Doctors are increasingly looking for income outside the normal practice of medicine. ìPain Managementî, ìCosmetic Surgeryî, ìLien Practiceî, ìSurgicentersî, and many other ìPartnershipsî are offered to physicians. When physicians enter into these and other situations for profit- the consequences may be considerable- including losing your medical license, paying fines, being thrown out of medical societies and specialty organizations, and even committing felonies and going to jail. In the last year, numerous physicians- including orthopedic spine and neurosurgical specialists have crossed the line and now are faced with dire consequences. A Las Vegas physician in now in jail for second degree murder. Another lost his license for purchasing non- FDA approved injectable medications. Other physicians attempting to cut costs allegedly used the same needles on multiple patients, thereby transmitting hepatitis C to seven confirmed patients thus far. The latter, almost costing all physicians the legislative removal of a hard fought malpractice cap on pain and suffering.
Methods: Analysis of newspaper reports, trail transcripts, medical board meetings were reviewed in great detail. The unethical involvement of the physicians was reviewed and characterized.
Results: The unethical conduct had direct consequences for the doctors involved- from paying fines, destroying their practices, their dismissal from medical staffs and even felony convictions. These cummulative ethical violation led the state’s trial lawyers to attempt to legislatively remove the malpractice cap on pain and suffering.
Conclusions: Unethical practices will eventually be discovered and the consequences to the phyician, has profession and colleagues may be profound and not only lower the esteem of physicians in the public eye but may have drastic economic consequences for all physicians.
Keywords: Ethics, Neurosurgeons, Associations, Fraud
Objectives: 1. Be more aware of when a situation may lead to an ethical violation. 2. Avoid unethical behavior. 3. Help colleagues who may be considering participating in a questionably ethical endeavor.
Subject: Tumor
Title: Hematopoietic cells within meningiomas
Authors: Lars Widdel; Bette K Kleinschmidt-Demasters; Glenn Kindt
Introduction: Tumor-to-tumor metastasis is a rare, but well-reported, curiosity in which usually one solid tumor type metastasizes to another. Often there are limited clinical consequences and the condition is an incidental finding only identified microscopically. Far less common is the occurrence of a hematopoietic neoplasm which is infiltrative of a brain tumor.
Methods: Retrospective chart review and pathological review on 3 patients with tumor to tumor metastasis of hematopoeitic cell cancers to intra-cranial meningiomas.
Results: We report three examples of meningiomas containing hematopoietic cells which in two cases were neoplastic. The first was a 54-year-old man with a dural mass overlying the left frontal lobe that was associated with significant edema. The patient was undergoing workup for a suspected systemic hematologic disorder, but the mass effects necessitated neurosurgical intervention. On histological examination, multiple myeloma cells permeated the otherwise benign meningioma. The second was a 45-year-old woman with known marginal zone lymphoma who then presented with a left frontal lobe lesion associated with considerable edema, again necessitating surgical intervention. Epi-, intra-, and subdural lymphoma (CD20+, Bcl-2+) was identified in her otherwise benign meningioma. The third case was a 49-year-old woman with a left frontotemporal meningioma containing profuse mast cells that prompted the original pathologist to consider a hypercellular atypical meningioma; this case showed extensive edema as well.
Conclusions: Hematopoietic cells within benign meningiomas can increase cerebral edema associated with the mass and may prompt emergent surgical resection.
Keywords: Meningioma, tumor metastasis, lymphoma, multiple myeloma
Objectives: 1.- Identify the ability of tumors to metastazise to other tumors. 2.- Recognize clinical features that suggest tumor to tumor metastasis has occurred. 3.- Apply therapeutic options to patients with these findings.
Subject: Trauma
Title: Chemical and Biological Terrorism and the Neurosurgeon
Authors: Howard Morgan
Introduction: As the months and years pass by after 9-11, Americans forget about that horrible day and the immediate aftermath.
Methods: Should we still be concerned about and prepare for another terrorist attach?
Results: What sort of weapons might terrorists use besides conventional explosives and hijacked commerical aircraft?
Conclusions: What does any of this have to do with neurosurgery?
Keywords: Terrorism, chemical terrorism, biological terrorism
Objectives: 1. Become acquainted with some of the more likely biological and chemical agents that we might comfront in a terrorist attack. 2. Realize there are treatments/antedotes for some but not all. 3. Appreciate where neurosurgery might fit in.