Successful use of the new high-dose mannitol treatment in patients with Glasgow Coma Scale scores of 3 and bilateral abnormal pupillary widening: a randomized trial

2004 ◽  
Vol 100 (3) ◽  
pp. 376-383 ◽  
Author(s):  
Julio Cruz ◽  
Giulio Minoja ◽  
Kazuo Okuchi ◽  
Enrico Facco
Keyword(s):  
Brain Death ◽  
Emergency Room ◽  
Clinical Outcomes ◽  
Clinical Signs ◽  
High Dose ◽  
Content Type ◽  
Conventional Dose ◽  
Diffuse Brain Swelling ◽  
Fine Print

Object. The authors evaluated long-term clinical outcomes in selected acutely comatose patients with severe diffuse brain swelling and recent clinical signs of impending brain death who received a novel high-dose mannitol treatment compared with those who received conventional-dose mannitol in the emergency room. Methods. Forty-four adult patients with traumatic, nonmissile-inflicted, acute, severe diffuse brain swelling were prospectively and randomly evaluated. All patients were selected based on the presence of recent clinical signs of impending brain death on the first emergency room evaluation. These signs included bilateral abnormal pupillary widening and lack of motor responses to painful stimulation (Glasgow Coma Scale score of 3). The study group (23 patients) received ultra-early and fast intravenous high-dose mannitol treatment (∼1.4 g/kg), whereas the control group (21 patients) received half that dose (∼0.7 g/kg). Ultra-early improvement of bilateral abnormal pupillary widening was significantly more frequent in the high-dose mannitol group than in the conventional-dose group (p < 0.02). High-dose mannitol treatment in the emergency room was also associated with significantly better 6-month clinical outcomes (p < 0.02); the best rate of favorable outcomes was 43.5%, compared with only 9.5% in the conventional-dose mannitol group. The two groups of patients were well matched with respect to all emergency room and head computerized tomography findings, as well as the timing of initial mannitol treatment (∼80–90 minutes after the first evaluation at the scene of the injury). Comparative evaluation of bilateral pupillary widening between the scene of the injury and the emergency room showed no significant differences between groups, whereas mannitol dose dependence was statistically significant (p < 0.05), insofar as early pupillary improvement in the emergency room was concerned. Conclusions. Ultra-early high-dose mannitol administration in the emergency room is the first known treatment strategy significantly to reverse recent clinical signs of impending brain death, and also to contribute directly to improved long-term clinical outcomes for these patients who have previously been considered unsalvageable.

Dual-isotope single-photon emission computerized tomography scanning in patients with glioblastoma multiforme: association with patient survival and histopathological characteristics of tumor after high-dose radiotherapy

1998 ◽  
Vol 89 (1) ◽  
pp. 60-68 ◽  
Author(s):  
Richard B. Schwartz ◽  
B. Leonard Holman ◽  
Joseph F. Polak ◽  
Basem M. Garada ◽  
Marc S. Schwartz ◽  
...  
Keyword(s):  
Survival Rate ◽  
Glioblastoma Multiforme ◽  
Single Photon ◽  
Photon Emission ◽  
High Dose ◽  
Term Survival ◽  
Content Type ◽  
Dual Isotope ◽  
Fine Print

Object. The study was conducted to determine the association between dual-isotope single-photon emission computerized tomography (SPECT) scanning and histopathological findings of tumor recurrence and survival in patients treated with high-dose radiotherapy for glioblastoma multiforme. Methods. Studies in which SPECT with 201Tl and 99mTc-hexamethypropyleneamine oxime (HMPAO) were used were performed 1 day before reoperation in 47 patients with glioblastoma multiforme who had previously been treated by surgery and high-dose radiotherapy. Maximum uptake of 201Tl in the lesion was expressed as a ratio to that in the contralateral scalp, and uptake of 99mTc-HMPAO was expressed as a ratio to that in the cerebellar cortex. Patients were stratified into groups based on the maximum radioisotope uptake values in their tumor beds. The significance of differences in patient gender, histological characteristics of tissue at reoperation, and SPECT uptake group with respect to 1-year survival was elucidated by using the chi-square statistic. Comparisons of patient ages and time to tumor recurrence as functions of 1-year survival were made using the t-test. Survival data at 1 year were presented according to the Kaplan—Meier method, and the significance of potential differences was evaluated using the log-rank method. The effects of different variables (tumor type, time to recurrence, and SPECT grouping) on long-term survival were evaluated using Cox proportional models that controlled for age and gender. All patients in Group I (201Tl ratio < 2 and 99mTc-HMPAO ratio < 0.5) showed radiation changes in their biopsy specimens: they had an 83.3% 1-year survival rate. Group II patients (201T1 ratio < 2 and 99mTc-HMPAO ratio of ≥ 0.5 or 201Tl ratio between 2 and 3.5 regardless of 99mTc-HMPAO ratio) had predominantly infiltrating tumor (66.6%); they had a 29.2% 1-year survival rate. Almost all of the patients in Group III (201Tl ratio > 3.5 and 99mTc-HMPAO ratio ≥ 0.5) had solid tumor (88.2%) and they had a 6.7% 1-year survival rate. Histological data were associated with 1-year survival (p < 0.01); however, SPECT grouping was more closely associated with 1-year survival (p < 0.001) and was the only variable significantly associated with long-term survival (p < 0.005). Conclusions. Dual-isotope SPECT data correlate with histopathological findings made at reoperation and with survival in patients with malignant gliomas after surgical and high-dose radiation therapy.

Craniopharyngioma in adults and children: a study of 122 surgical cases

2002 ◽  
Vol 97 (1) ◽  
pp. 3-11 ◽  
Author(s):  
Rémy Van Effenterre ◽  
Anne-Laure Boch
Keyword(s):  
Patient Survival ◽  
Postoperative Radiotherapy ◽  
Clinical Signs ◽  
Functional Results ◽  
Recurrence Risk ◽  
Tumor Removal ◽  
Content Type ◽  
Adults And Children ◽  
Fine Print

Object. This work is devoted to a 25-year retrospective study of 122 cases of craniopharyngiomas in adults and children treated and followed by the same neurosurgeon (R.V.E.). In this homogeneous series, the aim was total microsurgical removal of the tumor, without postoperative radiotherapy. Methods. The operation was performed via a frontopterional approach in 112 cases and a transsphenoidal approach in 10 cases. The tumor removal was considered total in 59%, subtotal in 29%, and partial in 12%. The surgical mortality rate was 2.5%. Even when tumor removal was not complete, radiotherapy was not systematically administered; it was reserved for cases of recurrence. The authors have studied clinical signs, operative characteristics, and ophthalmological, endocrinological, and functional outcomes, as well as recurrence risk and long-term patient survival. The mean follow-up period was 7 years. The functional results in these patients were excellent in 85%, good in 9%, fair in 5% (usually because of ophthalmological sequelae), and poor in 1%. Tumors recurred in 29 patients, but the salvage treatment, by operation or radiotherapy, was successful in 83%. The actuarial patient survival rate was 92% after 5 years and 85% after 10 years. Conclusions. These results compared favorably with the data reported in the literature, suggesting that radical surgery of craniopharyngiomas allows good outcome in terms of survival, full recovery, and quality of life for both adults and children.

Medulloblastoma: freedom from relapse longer than 8 years — a therapeutic cure?

1991 ◽  
Vol 75 (4) ◽  
pp. 575-582 ◽  
Author(s):  
Mark G. Belza ◽  
Sarah S. Donaldson ◽  
Gary K. Steinberg ◽  
Richard S. Cox ◽  
Philip H. Cogen
Keyword(s):  
Medical Center ◽  
Survival Rates ◽  
Adjunctive Treatment ◽  
High Dose ◽  
Content Type ◽  
Significant Difference ◽  
Long Term Follow Up ◽  
Fine Print

✓ Seventy-seven patients presenting with medulloblastoma between 1958 and 1986 were treated at Stanford University Medical Center and studied retrospectively. Multimodality therapy utilized surgical extirpation followed by megavoltage irradiation. In 15 cases chemotherapy was used as adjunctive treatment. The 10- and 15-year actuarial survival rates were both 41% with an 18-year maximum follow-up period (median 4.75 years). There were no treatment failures after 8 years of tumor-free survival. Gross total removal of tumor was achieved in 22 patients (32%); the surgical mortality rate was 3.9%. No significant difference was noted in the incidence of metastatic disease between shunted and nonshunted patients. The classical form of medulloblastoma was present in 67% of cases while the desmoplastic subtype was found in 16%. Survival rates were best for patients presenting after 1970, for those with desmoplastic tumors, and for patients receiving high-dose irradiation (≥ 5000 cGy) to the posterior fossa. Although early data on freedom from relapse suggested a possible beneficial effect from chemotherapy, long-term follow-up results showed no advantage from this modality of treatment. The patterns of relapse and survival were examined; 64% of relapses occurred within the central nervous system, and Collins' rule was applicable in 83% of cases beyond the period of risk. Although patients treated for recurrent disease could be palliated, none were long-term survivors. The study data indicate that freedom from relapse beyond 8 years from diagnosis can be considered as a cure in this disease. Long-term follow-up monitoring is essential to determine efficacy of treatment and to assess survival patterns accurately.

Laboratory criteria of brain death

1973 ◽  
Vol 39 (4) ◽  
pp. 429-433 ◽  
Author(s):  
Georges Ouaknine ◽  
Isaac Z. Kosary ◽  
Jackson Braham ◽  
Pinhas Czerniak ◽  
Hillel Nathan
Keyword(s):  
Brain Death ◽  
Laboratory Tests ◽  
Brain Temperature ◽  
Clinical Signs ◽  
Content Type ◽  
Bedside Tests ◽  
New Procedures ◽  
Fine Print

✓ Thirty patients with the clinical signs of brain death were subjected to a series of laboratory tests reputed to be capable of confirming this state. Three new procedures, electronystagmography, RISA intrathecal studies, and brain temperature tests, are described. The authors conclude that certain bedside tests, namely, electroencephalography, echoencephalography, electronystagmography, and electrocardiographic response to atropine, have been shown to be entirely adequate for a confident diagnosis.

Gamma knife radiosurgery in patients with advanced breast cancer undergoing bone marrow transplant

2002 ◽  
Vol 97 ◽  
pp. 663-665 ◽  
Author(s):  
Kenneth J. Levin ◽  
Emad F. Youssef ◽  
Andrew E. Sloan ◽  
Rajiv Patel ◽  
Rana K. Zabad ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Advanced Breast Cancer ◽  
Gamma Knife ◽  
Gamma Knife Radiosurgery ◽  
High Dose Chemotherapy ◽  
Advanced Breast ◽  
High Dose ◽  
Initial Management ◽  
Content Type ◽  
Fine Print

Object. Recent studies have suggested a high incidence of cognitive deficits in patients undergoing high-dose chemotherapy, which appears to be dose related. Whole-brain radiotherapy (WBRT) has previously been associated with cognitive impairment. The authors attempted to use gamma knife radiosurgery (GKS) to delay or avoid WBRT in patients with advanced breast cancer treated with high-dose chemotherapy and autologous bone marrow transplantation (HDC/ABMT) in whom brain metastases were diagnosed. Methods. A retrospective review of our experience from 1996 to 2001 was performed to identify patients who underwent HDC/ABMT for advanced breast cancer and brain metastasis. They were able to conduct GKS as initial management to avoid or delay WBRT in 12 patients following HDC/ABMT. All patients were women. The median age was 48 years (range 30–58 years). The Karnofsky Performance Scale score was 70 (range 60–90). All lesions were treated with a median prescription dose of 17 Gy (range 15–18 Gy) prescribed to the 50% isodose. Median survival was 11.5 months. Five patients (42%) had no evidence of central nervous system disease progression and no further treatment was given. Four patients were retreated with GKS and three of them eventually received WBRT as well. Two patients were treated with WBRT as the primary salvage therapy. The median time to retreatment with WBRT was 8 months after the initial GKS. Conclusions. Gamma knife radiosurgery can be effectively used for the initial management of brain metastases to avoid or delay WBRT in patients treated previously with HDC, with acceptable survival and preserved cognitive function.

Long-term hearing preservation after surgery for vestibular schwannoma

2005 ◽  
Vol 102 (1) ◽  
pp. 6-9 ◽  
Author(s):  
Simone A. Betchen ◽  
Jane Walsh ◽  
Kalmon D. Post
Keyword(s):  
Hearing Preservation ◽  
Magnetic Resonance Images ◽  
Class I ◽  
Repeated Testing ◽  
Content Type ◽  
Factors Influencing ◽  
Long Term Preservation ◽  
Fine Print

Object. Vestibular schwannomas (VSs) are now amenable to resection with excellent hearing preservation rates. It remains unclear whether immediately postoperative hearing is a durable result and will not diminish over time. The aim of this study was to determine the rate of long-term preservation of functional hearing following surgery for a VS and to examine factors influencing hearing preservation. Methods. All patients eligible for hearing preservation (Gardner—Robertson Class I or II) who had undergone resection of a VS by a single surgeon were reviewed retrospectively. Follow-up audiograms and magnetic resonance images were obtained. Of 142 patients deemed eligible for hearing preservation surgery, 38 had immediate postoperative hearing confirmed by an audiogram. In these patients with preserved hearing, the audiographic results demonstrated functional hearing in 30 (85.7%) of 35 patients who underwent repeated testing at a mean follow-up time of 7 years. Delayed hearing loss occurred in five (14.3%) of the 35 patients and did not correlate significantly with the size of the tumor. Hearing improved one Gardner—Robertson class postoperatively in three (7.9%) of the 38 patients. Conclusions. Long-term functional hearing was maintained in 85.7% of patients when it was preserved immediately postoperatively and the result was independent of tumor size. The results of this study emphasize that long-term preservation of functional hearing is a realistic goal following VS surgery and should be attempted in all patients in whom preoperative hearing is determined to be Gardner—Robertson Class I or II.

Surgical treatment for cervical spondylitic myelopathy

1995 ◽  
Vol 82 (5) ◽  
pp. 745-751 ◽  
Author(s):  
Michael J. Ebersold ◽  
Michel C. Pare ◽  
Lynn M. Quast
Keyword(s):  
Cord Compression ◽  
Term Outcome ◽  
Long Term Outcome ◽  
Content Type ◽  
Posterior Laminectomy ◽  
Anterior Decompression And Fusion ◽  
Anterior Group ◽  
Fine Print

✓ The long-term outcome of cervical spondylitic myelopathy after surgical treatment was retrospectively reviewed and critically evaluated in 100 patients with documented cervical myelopathy treated between 1978 and 1988 at our institution. Eighty-four patients were available for long-term study. The median duration of follow up was 7.35 years (range 3 to 9.5 years). There were 67 men and 17 women; their ages ranged from 27 to 86 years. The duration of preoperative symptoms ranged from 1 month to 10 years. Preoperative functional grade as evaluated with the Nurick Scale for the group was 2.1. Thirty-three patients with primarily anterior cord compression, one- or two-level disease, or a kyphotic neck deformity were treated by anterior decompression and fusion. Fifty-one patients with primarily posterior cord compression and multiple-level disease were treated by posterior laminectomy. There was no difference in the preoperative functional grade in these two groups. The patients in the posterior treatment group were older (59 vs 55 years). There was no surgical mortality from the operative procedures; morbidity was 3.6%. Of the 33 patients undergoing anterior decompression and fusion, 24 showed immediate functional improvement and nine were unchanged. Of the 51 patients who underwent posterior laminectomy, 35 demonstrated improvement, 11 were unchanged, and five were worse. Six patients, one in the anterior group and five in the posterior group, demonstrated early deterioration. Late deterioration occurred from 2 to 68 months postoperatively. Four (12%) patients who had undergone anterior procedures had additional posterior procedures, and seven (13.7%) patients who had undergone posterior procedures had additional decompressive surgery. The final functional status at last follow-up examination for the 33 patients in the anterior group was improved in 18, unchanged in nine, and deteriorated in six. Of the 51 patients who underwent posterior decompression, 19 benefited from the surgery, 13 were unchanged, and 19 were worse at last follow up than before their initial surgical procedure. Age, severity of disease, number of levels operated, and preoperative grade were not predictive of outcome. The only factor related to potential deterioration was the duration of symptoms preoperatively. The results indicate that with anterior or posterior decompression, long-term outcome is variable, and a subgroup of patients, even after adequate decompression and initial improvement, will have late functional deterioration.

Dorsal root entry zone lesions to control central pain in paraplegics

1981 ◽  
Vol 55 (3) ◽  
pp. 414-419 ◽  
Author(s):  
Blaine S. Nashold ◽  
Elizabeth Bullitt
Keyword(s):  
Dorsal Root ◽  
Central Pain ◽  
Entry Zone ◽  
Dorsal Root Entry Zone ◽  
Content Type ◽  
Root Entry Zone ◽  
Cord Injury ◽  
Fine Print

✓ Thirteen patients with intractable long-term pain following spinal cord injury and paraplegia were treated with dorsal root entry zone lesions placed at the level just above the transection. Pain relief of 50% or more was achieved in 11 of the 13 patients, with follow-up periods ranging from 5 to 38 months. A previous report showed that central pain from brachial plexus avulsion could be relieved by dorsal root entry zone lesions, and this technique has been extended to the central pain phenomena associated with spinal trauma and paraplegia.

Dynamic cranioplasty for brachycephaly in Apert syndrome: long-term follow-up study

2001 ◽  
Vol 94 (5) ◽  
pp. 757-764 ◽  
Author(s):  
José Guimarães-Ferreira ◽  
Fredrik Gewalli ◽  
Pelle Sahlin ◽  
Hans Friede ◽  
Py Owman-Moll ◽  
...  
Keyword(s):  
Cell Mass ◽  
Apert Syndrome ◽  
Long Term Results ◽  
Safe Procedure ◽  
Content Type ◽  
Skull Shape ◽  
The Mean ◽  
Fine Print

Object. Brachycephaly is a characteristic feature of Apert syndrome. Traditional techniques of cranioplasty often fail to produce an acceptable morphological outcome in patients with this condition. In 1996 a new surgical procedure called “dynamic cranioplasty for brachycephaly” (DCB) was reported. The purpose of the present study was to analyze perioperative data and morphological long-term results in patients with the cranial vault deformity of Apert syndrome who were treated with DCB. Methods. Twelve patients have undergone surgery performed using this technique since its introduction in 1991 (mean duration of follow-up review 60.2 months). Eleven patients had bicoronal synostosis and one had a combined bicoronal—bilambdoid synostosis. Perioperative data and long-term evolution of skull shape visualized on serial cephalometric radiographs were analyzed and compared with normative data. Changes in mean skull proportions were evaluated using a two-tailed paired-samples t-test, with differences being considered significant for probability values less than 0.01. The mean operative blood transfusion was 136% of estimated red cell mass (ERCM) and the mean postoperative transfusion was 48% of ERCM. The mean operative time was 218 minutes. The duration of stay in the intensive care unit averaged 1.7 days and the mean hospital stay was 11.8 days. There were no incidences of mortality and few complications. An improvement in skull shape was achieved in all cases, with a change in the mean cephalic index from a preoperative value of 90 to a postoperative value of 78 (p = 0.000254). Conclusions. Dynamic cranioplasty for brachycephaly is a safe procedure, yielding high-quality morphological results in the treatment of brachycephaly in patients with Apert syndrome.

Age at symptom onset and long-term survival in patients with neurofibromatosis Type 2

2003 ◽  
Vol 99 (3) ◽  
pp. 480-483 ◽  
Author(s):  
Goro Otsuka ◽  
Kiyoshi Saito ◽  
Tetsuya Nagatani ◽  
Jun Yoshida
Keyword(s):  
Symptom Onset ◽  
Survival Rates ◽  
Neurofibromatosis Type ◽  
Neurofibromatosis Type 2 ◽  
Vestibular Schwannomas ◽  
Content Type ◽  
Fine Print

Object. Neurofibromatosis Type 2 (NF2) is an intractable disorder predisposing to multiple, recurrent tumors of the central nervous system (CNS). To clarify the survival rate and characteristics that predict poor survival, we retrospectively reviewed clinical data in cases of NF2. Methods. From among 283 patients with neurofibromatosis who had been registered in a nationwide study in Japan between 1986 and 1987, 74 patients with bilateral vestibular schwannomas were analyzed. The mean duration of follow up after diagnosis was 121 months (range 2–287 months). Results of a Kaplan—Meier product-limit analysis indicated that overall 5-, 10-, and 20-year patient survival rates following diagnosis of NF2 were 85, 67, and 38%, respectively. Early onset of the initial symptom significantly compromised survival; 5-, 10-, and 20-year survival rates in patients with symptom onset at an age younger than 25 years were 80, 60, and 28%, respectively, whereas in patients with symptom onset at an age of 25 years or older the rates were 100, 87, and 62%, respectively. Patients with small vestibular schwannomas at diagnosis (< 2 cm in diameter) had better rates of survival. Other variables such as sex, additional tumors in the CNS, or dermal abnormalities did not significantly affect survival. Conclusions. This first report of long-term follow-up results concerning the survival of patients with NF2 indicates an adverse effect of early symptom onset.

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