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Neurocritical management of aneurysmal subarachnoid hemorrhage focuses on delayed cerebral ischemia (DCI) after aneurysm repair.This study conceptualizes the pathophysiology of cerebral ischemia and its management using a brain oxygen-directed protocol (intracranial pressure [ICP] control, eubaric hyperoxia, hemodynamic therapy, arterial vasodilation, and neuroprotection) in patients with subarachnoid hemorrhage, undergoing aneurysm clipping (n = 40).The brain oxygen-directed protocol reduced LboWe propose implications for clinical practice and patient management to minimize cerebral ischemia.

Before the 18th century, the vertebral venous plexus (VVP) received scant mention, had no clinical relevance, and was largely ignored by anatomists, most likely because of its location and nondistensible nature. Gilbert Breschet in 1819 provided the first detailed anatomic description of the VVP, describing it as a large plexiform valveless network of vertebral veins consisting of 3 interconnecting divisions and spanning the entire spinal column with connections to the cranial dural sinuses distributed in a longitudinal pattern, running parallel to and communicating with the venae cavae, and having multiple interconnections. More than a century passed before any work of significance on the VVP was noted. In 1940, Oscar V. Batson reported the true functionality of the VVP by proving the continuity of the prostatic venous plexus with the VVP and proposed this route as the most plausible explanation for the distribution of prostate metastatic disease. With his seminal work, Batson reclassified the human venous system to consist of the caval, pulmonary, portal, and vertebral divisions. Further advances in imaging technology confirmed Batson's results. Today, the VVP is considered part of the cerebrospinal venous system, which is regarded as a unique, large-capacitance, valveless plexiform venous network in which flow is bidirectional that plays an important role in the regulation of intracranial pressure with changes in posture and in venous outflow from the brain, whereas in disease states, it provides a potential route for the spread of tumor, infection, or emboli.

Objective Stereotactic radiosurgery has been used increasingly for the treatment of glomus jugulare tumors. The authors report their experience treating these tumors using gamma knife radiosurgery (GKRS), documenting the clinical and radiological outcome. Methods A retrospective analysis identified 17 patients with glomus jugulare tumors who underwent GKRS. Besides analysis of clinical outcome, a radiological volumetric analysis was also performed after treatment. Results There were 15 women and two men (average age, 63.1 yr) with a median follow-up period of 48 months. The median radiosurgical dose to the tumor margin was 15 Gy (range, 13-18 Gy). Eight patients (47.1%) improved clinically, two (11.8%) worsened, and seven (41.2%) were unchanged. No relationship between internal auditory canal dose and hearing loss was recorded. Tinnitus and otalgia were the symptoms that responded most favorably to GKRS. No patients experienced new lower cranial nerve palsies after GKRS. Tumor volume showed a transient increase in seven patients. Analysis of tumor volume at the time of the last magnetic resonance imaging scan recorded a decrease in eight patients, an increase in four patients, and no change in five patients. Conclusion GKRS is a safe, effective treatment for glomus jugulare tumors, particularly in patients with preserved glossopharyngeal and vagus nerve function, after surgical recurrence, in the elderly, and in patients with serious preexisting medical conditions. Longer follow-up periods are required to assess long-term effects.

The introduction of multiple front-end technologies during the past quarter century has generated an emerging futurism for the discipline of neurological surgery. Driven primarily by synergistic developments in science and engineering, neurosurgery has always managed to harness the potential of the latest technical developments. Robotics represents one such technology. Progress in development of this technology has resulted in new uses for robotic devices in our discipline, which are accompanied by new potential dangers and inherent risks. The recent surge in robot-assisted interventions in other disciplines suggests that this technology may be considered one of a spectrum of frontier technologies poised to fuel the development of neurosurgery and consolidate the era of minimalism. On a more practical level, if the introduction of robotics in neurosurgery proves beneficial, neurosurgeons will need to become facile with this technology and learn to harness its potential so that the best surgical results may be achieved in the least invasive manner. This article reviews the role of robotic technology in the context of neurosurgery.

Study design Retrospective review of 110 patients undergoing spinal dural repair and regeneration using an onlay, suture-free, 3-dimensional-collagen matrix graft (DuraGen) over an 8-year period (1995-2003). Objectives Technique appraisal of collagen matrix to repair spinal dura following incidental durotomy, spinal tumor surgery, and trauma. Summary of background data Traditional methods of spinal dural repair following incidental durotomy involve tedious attempts at primary watertight suture with a 5% to 10% failure rate. Dural injury occurs after trauma, or dural excision may be required after tumor resection. Collagen matrix is a newer development in collagen sponge. Methods The clinical and demographic data included diagnosis, type and site of surgery, infection risk, size of defect, use of lumbar drains, closed suction subfascial drains, and adverse events. The primary endpoints of graft failure were cerebrospinal fluid leak and pseudomeningocele formation. Neurosurgical wound infection rates were determined. Results Collagen matrix was used (n = 110) in the following conditions: degenerative (69), pseudomeningocele formation repair (4), tumors (14), trauma (13), and congenital (5). There were 15 cervical (10 anterior), 21 thoracic (3 anterior), and 71 lumbar (all posterior) surgeries. Fibrin glue was used in 7.3%, subfascial drains in 82%, and lumbar drainage in 2.7%. Overall, cerebrospinal fluid leaks occurred in 2.7%. The 2 pseudomeningocele formations (3.2%) resolved at 3 months. There were 2 wound infections. In the subgroup with incidental durotomy (n = 69), failure of cerebrospinal fluid containment occurred in 4.3% [1 cerebrospinal fluid leak (1.4%), 2 pseudomeningocele formations (2.9%)]. Conclusions Collagen matrix was successful in cerebrospinal fluid containment in > 95% of patients requiring dural repair following anterior and posterior spinal surgery. Subfascial drains were safe. Routine lumbar drains are not required but are recommended for repair of established pseudomeningocele formations.

It is just over a century since successful brain tumor resection. Since then the diagnosis, imaging, and management of brain tumors have improved, in large part due to technological advances. Similarly, the operating room (OR) for brain tumor surgery has increased in complexity and specificity with multiple forms of equipment now considered necessary as technical adjuncts. It is evident that the theme of minimalism in combination with advanced image-guidance techniques and a cohort of sophisticated technologies (e.g., robotics and nanotechnology) will drive changes in the current OR environment for the foreseeable future. In this report we describe what may be regarded today as standard essentials in an operating room for the surgical management of brain tumors and what we believe to be the current 'state-of-the-art' brain tumor OR. Also, we speculate on the additional capabilities of the brain tumor OR of the near future.

Overactivation of epidermal growth factor receptor (EGFR) signaling has been recognized as an important step in the pathogenesis and progression of multiple forms of cancer of epithelial origin. This knowledge has led to a surge of interest in novel anticancer therapies targeting key constituents of the EGFR signal transduction pathway. Several molecular strategies have been developed recently to modulate either EGFR or the downstream signal beyond the cell surface receptor. The important role of aberrant EGFR signaling in the progression of malignant gliomas makes EGFR-targeted therapies of particular interest in this form of cancer. The use of anti-EGFR therapies against malignant brain tumors, although in its infancy, promises to yield exciting results as these new drugs probably will enhance the usefulness of existing therapies.

BACKGROUND: Stereotactic radiosurgery is the priocipal therapeutic alternative to resecting benign intracranial tumors. The goals of radiosurgery are the long-term prevention of tumor growth, the maintenance of patient function, and the prevention of new neurological deficits or adverse radiation effects. Evaluation of long-term outcomes more than 10 years after radiosurgery is needed. METHODS: We evaluated 285 consecutive patients who underwent radiosurgery for benign intracranial tumors between 1987 and 1992. Serial imaging studies were obtained, and clinical evaluations were performed. Our series included 157 patients with vestibular schwannomas, 85 patients with meningiomas, 28 patients with pituitary adenomas, 10 patients with other cranial nerve schwannomas, and 5 patients with craniopharyngiomas. Prior surgical resection had been performed in 44% of these patients, and prior radiotherapy had been administered in 5%. The median follow-up period was 10 years. RESULTS: Overall, 95% of the 285 patients in this series had imaging-defined local tumor control (63% had tumor regression, and 32% had no further tumor growth). The actuarial tumor control rate at 15 years was 93.7%. In 5% of the patients, delayed tumor growth was identified. Resection was performed after radiosurgery in 13 patients (5%). No patient developed a radiation-induced tumor. Eighty-one percent of the patients were still alive at the time of this analysis. Normal facial nerve function was maintained in 95% of patients who had normal function before undergoing treatment for acoustic neuromas. CONCLUSION: Stereotactic radiosurgery provided high rates of tumor growth control, often with tumor regression, and low morbidity rates in patients with benign intracranial tumors when evaluated over the long term. This study supports radiosurgery as a reliable alternative to surgical resection for selected patients with benign intracranial tumors.

To determine the effect of 8-hourly administration of 10 mg intravenous metoclopramide, over a 48-h period on gastric emptying in severe head injury (SHI), 22 patients were prospectively randomized (Glasgow Coma Score of 3-8) to receive 2 ml of intravenous metoclopramide or 2 ml of 5% saline 8-hourly for 48 h. Baseline and serial blood paracetamol absorption assays were performed at time (t) = 0, 15, 30, 45, 60, 90 and 120 min on day 0 and day 2. The area under the curve between the day 0 and day 2 was used to measure the degree of gastric emptying. In SHI, sequential doses of metoclopramide did not appear to improve gastric motility within subject comparisons (p = 0.65) and between subject comparisons (placebo p = 0.4 and drug p = 0.12). Metoclopramide has no significant prokinetic effect on gastric emptying in SHI patients when given in the early postinjury period.

BACKGROUND Craniocerebral missile injuries have steadily increased to become the most common form of penetrating neurotrauma in our environment resulting in continued morbidity and neuropsychological sequelae. Civilian infratentorial gunshot injuries are uncommon but generally regarded as fatal injuries, with many patients dying before reaching hospital. METHODS A retrospective analysis of 1,069 patients with civilian gunshot wounds (GSW), admitted to our unit over a 14-year period (1986–2000), identified 26 patients with infratentorial gunshot injuries (2.4%). A detailed analysis of these patients was carried out, which included demographic factors, clinical and anatomic correlation, computed tomography scans, surgical management, and outcome. RESULTS All patients were male. The mean age was 26.5 ± 11.5 years and the mean admission Glasgow Coma Score 11.8 ± 2.7. Twenty-four of 26 patients required cerebrospinal fluid (CSF) diversion to control secondary hydrocephalus. The second commonest surgical procedure was posterior fossa decompression. Five of 26 patients died (19.2%). Severe morbidity was noted in 9 of 21 surviving patients (42.8%). Significant predictors: good outcome was associated with primary missile entry of the infratentorial compartment ( p = 0.005), while patients with supratentorial to infratentorial missile trajectory were noted to have a poorer outcome ( p = 0.041). Location of cerebellar injury (lateral or medial) and missile caliber had no significant influence on patient outcome. CONCLUSION Early control of incipient or established hydrocephalus and aggressive surgical management where appropriate, with careful postoperative monitoring, is necessary for good outcome in patients with civilian infratentorial missile injuries.

We report a unique case of a self-inflicted brain injury using an ingenious home-made gun with spontaneous anterior migration of the intact bullet. On admission, the patient was fully conscious with no neurological deficits. Computed tomography (CT) confirmed a penetrating missile injury with transventricular across midline trajectory and multi-lobe injury with the bullet lodged in the occipital lobe. Serial CT revealed spontaneous version with anterior migration of the bullet from the occipital lobe to finally come to rest in the ipsilateral frontobasal region. The bullet was removed via a left supra-orbital craniotomy. The patient experienced good outcome. Home-made gun injuries, although uncommon today, represent a special form of missile injury with unique low velocity terminal ballistics. As these weapons are seen infrequently today, surgeons should be alerted to their existence as patients with this form of injury usually have a good prognosis if vital brain structures are spared.

OBJECTIVE Uncertainty regarding the best surgical management for subdural empyemas (SDEs) continues. Our unit has considered craniotomy the preferred method of surgical drainage for all cranial SDEs since 1988. We performed an analysis of our previously published, computed tomography-era, experience with 699 patients. METHODS Two analyses of the database (1983–1997) were performed. First, analysis of the periods from 1983 to 1987 and from 1988 to 1997 was performed. Second, analysis of the composite database was performed. Outcomes were compared for possible outcome predictors by univariate analysis. Multivariate analysis was used to identify variables that contributed independently to outcomes, using stepwise discriminant analysis. RESULTS Significant correlations between the analyzed periods with respect to outcome and type of surgery (P = 0.001) were noted. Analysis of the entire database (1983–1997) revealed a significant relationship between outcome and surgery type (P = 0.05). Pairwise comparison of limited procedures such as burr holes or craniectomies with wide-exposure surgical procedures such as primary craniotomies or procedures proceeding to full craniotomies indicated significant correlation with outcomes (P = 0.027). Reoperation and morbidity rates were increased with limited procedures. Stepwise discriminant analyses revealed that the type of surgery was correlated with outcomes (P = 0.0008, partial r2 = 0.034). CONCLUSION Craniotomy was determined to be the surgical procedure of choice for treatment of cranial SDEs, allowing complete evacuation of the pus and, more importantly, decompressing the underlying cerebral hemisphere. Limited procedures such as burr holes or craniectomies may be performed for patients in septic shock, for patients with parafalcine empyemas, or for children with SDEs secondary to meningitis.

OBJECTIVE Transcranial stab injuries remain a frequent cause of emergent neurosurgical admissions to neurosurgical units in South Africa. Brainstem stabs are an uncommon, yet often fatal, form of brain injury. METHODS A retrospective audit of 597 patients with transcranial stab injuries admitted to our unit over a 12-year period (January 1987 to December 1998) identified 17 patients (2.85%) with brainstem stab injuries. The computed tomographic scans of all patients were analyzed, and a detailed autopsy examination of the skull and its contents was performed in all patients who died. Stepwise linear regression analysis was used to formulate a predictive model of outcome for the entire series of 597 patients. RESULTS The majority of the patients were males (16 patients), and the study group had a mean age of 28.65 ± 9.59 years and a mean Glasgow Coma Scale score of 8.59 ± 2.76. Knives (82%) were the most common instruments of penetration. Cerebral angiography identified 3 patients with vascular abnormalities, and autopsy revealed an additional 4 patients with vascular injury. Emergency ventriculostomy was performed in 10 patients for obstructive hydrocephalus. Four of the 17 patients survived (76.5% mortality). Factors significantly predictive of outcome in patients with transcranial stab injuries were the Glasgow Coma Scale score (F = 43.7), the occurrence of intraventricular hemorrhage (F = 22.8), the type of associated lesion (intracranial bleed, vascular abnormality, or brain abscess) (F = 5.9), and the number of operations (F = 3.2). CONCLUSION The Glasgow Coma Scale score is the most significant predictor of outcome in low-velocity transcranial stab injuries. Brainstem stab injuries have a great propensity for vascular damage. Survivors are incapacitated by severe, fixed neurological deficits.

OBJECTIVE Tuberculous meningitis (TBM) and its complications continue to have devastating neurological consequences for patients. Budgetary constraints, especially in developing countries, have made it necessary to select patients for shunting who are likely to experience good recoveries. To date, the value of cerebrospinal fluid shunting for human immunodeficiency virus (HIV)-positive patients with TBM has not been clearly established. METHODS Thirty patients with TBM and hydrocephalus were prospectively evaluated. Coincidentally, one-half of the patients were HIV-positive. All patients underwent uniform treatment, including ventriculoperitoneal shunt placement and antituberculosis treatment. CD4 counts were measured for all patients. Outcomes were assessed at 1 month. RESULTS No complications related to shunt insertion were noted. The HIV-positive group fared poorly (death, 66.7%; poor outcome, 64.7%), compared with the HIV-negative group (death, 26.7%; poor outcome, 30.8%). Despite cerebrospinal fluid shunting, no patient in the HIV-positive group experienced a good recovery (Glasgow Outcome Scale score of 5). This is in contrast to the six patients (40%) in the HIV-negative group who, with the same treatment, experienced good recoveries (Glasgow Outcome Scale scores of 5) at discharge (P < 0.14). No patient (either HIV-positive or HIV-negative) who presented in TBM Grade 4 survived, whereas no HIV-positive patient who presented in TBM Grade 3 survived. A significant relationship was noted between CD4 counts and patient outcomes (P < 0.031). CONCLUSION In the absence of obvious clinical benefit, HIV-positive patients with TBM should undergo a trial of ventricular or lumbar cerebrospinal fluid drainage, and only those who exhibit significant neurological improvement should proceed to shunt surgery.

Objective Intracranial empyemas are the most common form of intracranial suppuration seen in our unit and, despite modern antibiotic therapy and advanced neurosurgical and imaging facilities, these pus collections remain a formidable challenge, often resulting in significant morbidity and death. We present an analysis of our 15-year experience with this condition in the era of computed tomography. Methods A retrospective analysis of 4623 patients admitted with intracranial sepsis during a 15-year period (1983-1997) identified 699 patients with intracranial subdural empyemas. The inpatient notes for these patients were analyzed with respect to clinical, radiological, bacteriological, surgical, and outcome data. Statistical analyses were performed. Results The 699 intracranial subdural empyemas accounted for 15% of all admissions for intracranial sepsis during the study period. Young male patients in the second or third decade of life were most commonly affected (62%), and the mean age was 14.65+/-12.2 years. Almost all patients (96%) underwent surgery. Eighty-two percent of patients experienced good outcomes (Glasgow Outcome Scale scores of 4 or 5). A morbidity rate of 25.9% (including postoperative seizures) was noted, and 85 patients died (mortality rate, 12.2%). Conclusion Intracranial subdural empyema, which is a neurosurgical emergency, is rapidly fatal if not recognized early and managed promptly. Early surgical drainage, simultaneous eradication of the primary source of sepsis, and intravenous administration of high doses of appropriate antibiotic agents represent the mainstays of treatment.

Intracranial suppurative complications from neglected rhinoenic sinusitis in the developed world are an uncommon ccurrence. However, the increased use of immune suppressive herapy and patients with chronic inflammatory, immunosuprsessive disorders, has exposed patients to an increased risk of nfectious complications with the potential for unusual clinical resentations. Patients with inflammatory bowel disease are suseptible to infectious complications and more so in the presence of mmunosuppressive therapy. We report an interesting complicaion of multifocal central nervous and peripheral abscesses due to hinogenic sinusitis in a patient with Crohn’s disease.

Intracranial suppurative disorders (ICSDs; brain abscess, empyema, and purulent ventriculitis), have been a scourge through the ages and attempts at curative surgery, as for cranial trauma, are considered to be one of the first true neurosurgical interventions performed. ICSDs, seen initially as a consequence of poor socioeconomic conditions and neglected otorhinogenic infections, predominantly manifest today as postsurgical complications, and/or in immunocompromised patients where they continue to result in significant neurologic morbidity and death. The reduction in the incidence of "old world" classic ICSDs can be attributed to the modernization of society, driven inter alia by a shift from an agricultural to an industrial economic society. It can also be coupled with pivotal achievements in public health and the dramatic developments in medicine in the 20th century. This trend was first noted in developed countries but now, with improved socioeconomic circumstances and globalization of medical technology, it is occurring in the developing regions of the world as well. Although ICSDs have undergone a metamorphosis in their clinical profile and despite their rarity in contemporary "developed world" neurosurgical practice, they still have undoubted potential for fatal consequences and continue to pose a significant challenge to the 21st-century neurosurgeon.

Objective Brain abscess (BA) is a neurosurgical emergency and despite significant medical advances, it remains a surgical challenge. A single institution's two decade computed tomography era management experience with BA is reported. Methods A retrospective analysis of patients with BA, admitted to the Department of Neurosurgery, Wentworth Hospital, Durban, KwaZulu-Natal, South Africa, was performed. The medical records were analyzed for demographic, clinical, neuroimaging, neurosurgical and otolaryngology management, microbiological characteristics, and their relationship to outcome. Results During a 20-year period (1983–2002), 973 patients were treated. The mean age was 24.36 ± 15.1 years (range: 0.17–72 years) and 74.2% (n = 722) were men. The mean admission Glasgow Coma Score was 12.5 ± 2.83. The majority of BAs were supratentorial (n = 872, 89.6%). The causes were otorhinogenic (38.6%), traumatic (32.8%), pulmonary (7%), cryptogenic (4.6%), postsurgical (3.2%), meningitis (2.8%), cardiac (2.7%), and “other” (8.6%). Surgical drainage was performed in 97.1%, whereas 19 patients had nonoperative management. The incidence of BA decreased during the study period. Patient outcomes were good in 81.3% (n = 791), poor in 5.3% (n = 52), and death (13.4%, n = 130) at discharge. The management morbidity, which included postoperative seizures, was 24.9%. Predictors of mortality were cerebral infarction (odds ratio [OR] 31.1), ventriculitis (OR 12.9), coma (OR 6.8), hydrocephalus (OR 5.1), dilated pupils (OR 4.8), bilateral abscesses (OR 3.8), multiple abscesses (OR 3.4), HIV co-infection (OR 3.2), papilledema (OR 2.6), neurological deterioration (OR 2.4), and fever (OR 1.7). Conclusions Optimal management of BA involves surgical drainage for medium-to-large abscesses (≥2.5 cm) with simultaneous eradication of the primary source, treatment of associated hydrocephalus, and administration of high doses of intravenous antibiotics. The incidence of BA is directly related to poor socioeconomic conditions and therefore, still poses a public health challenge in developing countries.

GEORGE W. CRILE is best known as the father of physiological surgery in the United States, a pioneer surgeon, an innovator and inventor, a founding member of the American College of Surgeons, and the principal founder of the Cleveland Clinic Foundation. However, Crile's legacy of performing the first direct blood transfusion in humans has been all but forgotten, even though the results were published in the leading scientific journals of the day. Crile's lifelong interest in the treatment of surgical shock led to his interest in blood transfusion. A chance visit to the laboratory of Alexis Carrel in 1902 resulted in Crile perfecting his technique for direct blood transfusion. He subsequently modified Carrel's anastomosis technique to administer a faster transfusion, investigated the use of blood transfusions in various clinical settings, and went on to introduce the concept and technique of blood transfusion to soldiers during World War I. In this report, we trace his long-time interest in blood transfusion and document the events that led to the first successful blood transfusion performed between 2 brothers on August 6, 1906, at St. Alexis Hospital, Cleveland, OH.

OBJECTIVE 5-Lipoxygenase (5-LO) oxidizes arachidonic acid into proinflammatory eicosanoids that may promote tumorigenesis. In this study, we investigated whether 5-LO is expressed in human astrocytomas and what effect its expression may have on patient outcome. METHODS Increased 5-LO messenger ribonucleic acid and protein expression was detected by the polymerase chain reaction and antibody-based approaches, respectively, in surgical astrocytoma specimens and established glioblastoma multiforme cell lines compared with primary cell culture from the human white matter. RESULTS Immunohistochemical analysis revealed predominantly nuclear 5-LO staining in 44 of 49 glioblastoma multiforme samples (90%), 8 of 10 (80%) anaplastic astrocytomas samples, and 3 of 13 (23%) low-grade astrocytoma samples analyzed. Double-staining experiments with anti-CD-68 (macrophage/microglial marker) and anti-5-LO antibodies suggest that both CD-68-positive and CD-68-negative tumor cells express 5-LO protein. Staining of 5-LO was significantly more frequent in high-grade than in low-grade tumors (P = 0.001). Patients whose tumors expressed 5-LO were significantly older, had lower preoperative Karnofsky performance scores and shorter survival than patients whose tumors did not express 5-LO. After adjusting for pathological diagnosis and age, respectively, neither Karnofsky performance score nor survival were significantly associated with 5-LO staining. CONCLUSION These data indicate that 5-LO is overexpressed in high-grade astrocytomas and supports the idea that eicosanoids may play a role in tumorigenesis of these brain tumors.

Meningiomas are common brain tumors with somatostatin receptors that bind octreotide. We report the use of 111indium-octreotide brain scintigraphy (OBS) for the non-invasive differentiation of meningiomas from other cranial dural-based pathology. A retrospective analysis of our experience with OBS for non-invasive identification of meningiomas was performed. Two neuroradiologists, blinded to clinical data, utilized a standardized grading scheme to define the uptake of octreotide at 6 and 24 h post-administration. The correlation between (18) F-fluoro-2-deoxy-d-glucose positron emission tomography (FDG-PET), magnetic resonance imaging (MRI) scans, and octreotide uptake was assessed. The cohort consisted of 50 patients having a mean age of 62.4 years and a median follow-up time of 24 months. Management consisted of biopsy (n = 4); resection (n = 10); observation (n = 16); radiosurgery (n = 21); and external beam radiotherapy (n = 3). OBS was correlated with MRI (n = 50); FDG-PET brain studies (n = 38); histology (n = 14), and angiography (n = 1). In cases where definitive diagnosis could be made, the sensitivity, specificity, positive and negative predictor values for OBS alone were 100; 50; 75; and 100, respectively. OBS provided false positive data in 3 patients (metastasis, chronic inflammation, lymphoma). Use of OBS with MRI to differentiate meningiomas from other lesions was highly significant (P

Brain metastases are ten-times more common than primary brain tumors and are a common complication in patients with systemic cancer. The most common sources of brain metastases are lung and breast cancers, although in 15% of patients, the primary site is unknown. Optimal treatment is dependant upon tumor location, size, number of tumors and status of the systemic disease. Currently, management of brain metastases with surgery, radiotherapy and stereotactic radiosurgery is known to improve the quality of life and even life expectancy for selected patients. Techniques under investigation include focal radiation techniques, magnetic resonance imaging guided thermal ablation of metastases, drug delivery modes that bypass the blood-brain barrier and novel drug and molecular therapeutics. Efforts are ongoing to understand the molecular biology of brain metastases.

Summary Aim To compare the efficacy of blind transpyloric placement using a specifically designed nasojejunal tube (NJT) versus a standard nasogastric tube (NGT) in severe head injury (SHI). Methods This was a randomised trial conducted in a neurosurgical intensive care unit. Fourteen patients were enrolled with a Glasgow Coma Score (GCS) less than 8 (mean 6.8 SEM ± 0.36). Patients were randomised to receive either NJT or NGT. Results There was an 83% (5/6 patients) spontaneous jejunal placement rate of NJT past the ligament of Treitz. The 17% (1/6 patients) jejunal placement failure rate for NJT was due to inappropriate technique. A 100% (8/8 patients) failure of the unweighted NGTs to pass through the pylorus into the jejunum was recorded (P = 0.002). Conclusion In SHI, the specifically designed self-propelling NJT was effective in spontaneous transpyloric placement past the ligament of Treitz within 12 h of introduction into the gastric cavity. The standard un-weighted NGT was ineffective. Additional studies are warranted to determine the clinical efficacy of this self-propelling NJT.

Patients with acute brain pathology requiring ferromagnetic bio-medical implants for on-going invasive monitoring are largely excluded from the benefits of MRI scanning. We evaluated the behaviour of a thermal diffusion cortical blood flow (TD-CBF) sensor both in vitro (phantom gelatin model) and in vivo environments in a high field strength MRI system. Two baboons underwent cranial subdural implantation of 2 TD-CBF sensors/hemisphere and a single left parietal sensor was implanted subcortically to determine any deleterious effects. Using standard MRI sequences, artefact size, thermal effects, current generation, movement and reliability of recordings were assessed during scanning. The deflection forces were negligible, no observable thermal effects were demonstrated, while wide fluctuations in cerebral blood flow recordings were recorded. Mean image artefact size for implanted sensors was 6 times larger than in vitro. Patients with an implanted TD-CBF sensor may be safely imaged provided the device is disconnected. The MRI images obtained are of an acceptable quality.

Background Many authors have strongly cautioned against the performance of lumbar puncture in patients with suspected or likely infective intracranial mass lesions due to the dubious value of the CSF analysis so obtained, and due to the inherent danger of clinical deterioration precipitated by a pressure cone. Objective To assess the role of lumbar puncture (LP) in aiding diagnosis and influencing outcome in patients with intracranial brain abscess or subdural empyema. Methods The records of patients admitted with space occupying intracranial infective mass lesions (brain abscess and subdural empyema) to the neurosurgical unit at Wentworth Hospital, Durban, over a 15 year period, were retrospectively reviewed. Of the 1411 patients admitted with intracranial suppurative disorders (brain abscess = 712) and subdural empyemas (699), 422 (29.9%) underwent diagnostic LP prior to referral to our unit. The records of these 422 patients were studied in more detail with regard to the result of the LP and it\'s effect on patient outcome. Results of the LP were analysed in order to determine the contribution of LPto the diagnosis. The impact of the LP on patient outcome was assessed. Results The cerebrospinal fluid (CSF) examination was normal in 66 (15.6%) and equivocal in 283 (67.1%). Bacterial meningitis was diagnosed in 73 (17.3%) and organisms cultured in 42 (10.0%). As suspected, 272 patients (64.5%) underwent clinical deterioration following lumbar puncture. In 81 patients (19.2%) the clinical deterioration was directly attributable to the lumbar puncture and 20 patients (4.7%) died as a result of LP. Conclusion In patients with brain abscess or subdural empyema, LP contributes little to diagnosis while significantly increasing the risk of clinical deterioration and even death. Patients suspected of harbouring infective intracranial mass lesions should undergo computed tomography (CT) prior to LP or should be placed onto empiric antibiotic therapy until a CTscan can be obtained. Keywords: cerebrospinal fluid, intracranial brain abscess, lumbar puncture, subdural empyema, abces intracrânien, empyeme sous-dural intra-crânien, liquide cerebro-spinal, ponction lombaire Resume Introduction Plusieurs auteurs ont insiste sur le caractere inutile et dangereux de pratiquer une ponction lombaire (PL) lorsque l\'on suspecte un processus expansif intracrânien d\'origine infecteuse a cause du risque d\'engagement. Objectif Evaluer le role de la PL au plan diagnostique et etudier son influence sur l\'evolution des abces et empyemes sous - duraux intra-crâniens. Methodes Les dossiers des patients hospitalises pour des lesions infectieuses intracrâniennes pendant 15 ans et admis dans le departement de neurochirurgie du Wentworth Hospital, Durban ont ete etudies retrospectivement. Sur les 1411 patients hospitalises pour suppuration intracrânienne (abces cerebraux = 712) et empyemes sous – duraux (699), 422 (29,9%) ont subi une PL avant d\'etre admis dans notre service. Les dossiers de ces 422 patients ont ete etudies. Resultats Le liquide cerebro-spinal (LCS) etait normal dans 66 cas (15,6%) et equivoque dans 283 cas (67,1%). Une meningite bacterienne a ete diagnostiquee dans 73 cas (17,3%) avec presence de germes dans 42 cas (10%). 272 patients (64,5%) eurent une deterioration clinique apres la PL. Chez 81 patients (19,2%) l\'aggravation clinique etait en rapport avec la PL. 20 patients (4,7%) decederent a cause de la PL. Conclusion Chez les patients ayant un abces ou un empyeme sous - dural intra-crânien la PL accroit de facon significative le risque de deterioration clinique voire la mort. Tout patient suspect de processus expansif intra-crânien doit beneficier du CT-scan avant de pratiquer une PLou devra bene - ficier d\'un traitement antibiotique empirique avant la realisation du CT-scan. Af J Neuro Sci: 2001 20(1)

A 15-year (1983-1997) review of our unit's computed tomographic experience with traumatic cranial empyema (TCE) is reported. Fifty-five patients with documented history and clinical evidence of neurotrauma with secondary cranial empyema at surgery were identified. The clinical records and CT scans were analysed. TCE [four extradural and 51 subdural collections (SDE)] accounted for 7.86% of the total cranial empyemas seen during the study period. Most of the patients were young males (44 patients) and neurological deficits on admission were found only in the SDE group. Forty-one of 53 patients presented with septic compound skull fractures. Fifty-four patients had urgent surgical drainage. Eighty per cent of patients experienced a good outcome (GOS 4 or 5). A morbidity of 16.4% (including postoperative seizures) was noted and eight patients died (mortality rate 14.5%). Urgent surgical drainage, removal of osteitic bone, wound debridement and high dose intravenous antibiotic therapy form the mainstay of treatment.

Objective Intracranial suppurative disorders (abscesses and empyemas) continue to be common neurosurgical emergencies in South Africa. Cranial extradural empyema (EDE) occurs less frequently than its subdural counterpart but remains a potentially devastating disease process. We present our 15-year experience with this condition in the era of computed tomography. Methods Of the 4623 patients with intracranial sepsis who were admitted to the neurosurgical unit at Wentworth Hospital (Durban, South Africa) during a 15-year period (1983-1997), 76 patients with EDEs were identified. An additional six patients who were identified from our outpatient records were treated nonsurgically. Analyses were performed with respect to clinical, radiological, bacteriological, surgical, and outcome data. All information for this study was obtained from the computerized databank for the unit. Statistical analyses of the related pre- and postoperative clinical data were performed. Results The 76 patients with EDEs accounted for 1.6% of the total number of patients admitted for treatment of intracranial sepsis during the study period. Thirteen patients (15.8%) had infratentorial pus collections. Male patients predominated by a ratio of 2:1, and 66 patients were between the ages of 6 and 20 years (mean age, 16.56+/-9.87 yr). The origins of the sepsis were paranasal sinusitis for 53 patients (64.6%), mastoiditis for 16 patients, trauma for 5 patients, dental caries for 1 patient, and miscellaneous causes for 7 patients. The most common clinical presenting features were fever, neck stiffness, and periorbital edema. Surgery was performed in the form of burrholes for 21 patients, small craniectomies for 39 patients, and craniotomies for 5 patients. The additional five patients, while having drainage of their infected paranasal sinuses, had simultaneous drainage of their extradural pus collections by the ear, nose, and throat surgeon. The majority of patients (81 patients) experienced good outcomes (Glasgow Outcome Scale scores of 4 or 5). A single patient died after surgery (mortality rate, 1.22%). Conclusion EDEs occur less frequently than subdural empyemas and are associated with better prognoses. Surgical drainage (burrholes), simultaneous eradication of the source of sepsis, and high-dose intravenous antibiotic therapy remain the mainstays of treatment. Selective nonsurgical management of small EDEs is possible, provided the source of sepsis is surgically eradicated. It is our opinion that EDE is a disease that should be managed without morbidity or death.

Objective and importance Many types of neurotuberculosis have been described; the most common intracranial forms are tuberculous meningitis and tuberculomas. We report a unique and as yet unreported form of neurotuberculosis, which is an intracranial tuberculous subdural empyema. Clinical presentation A 59-year-old man who had been previously treated for pulmonary tuberculosis (TB) presented at our institution with a long-standing history of headaches. General and neurological examinations revealed no abnormalities. Radiography of the chest confirmed fibrotic lung changes caused by healed pulmonary TB. A cranial computed tomographic scan revealed a hypodense extra-axial collection with mass effect as well as adjacent osteitis and scalp swelling. Intervention The patient underwent craniectomy of the osteitic bone and drainage of 50 ml of fluid pus located subdurally. Microscopic examination of the bone and pus revealed tuberculous granulation tissue with numerous acid-fast bacilli identified using Ziehl-Neelsen stain. Mycobacterium TB bacillus was cultured from the pus at 42 days. The patient required two further operative procedures as well as a protracted course of anti-TB therapy. Conclusion The patient eventually achieved a good recovery. We recommend surgical drainage of tuberculous subdural empyema to relieve mass effect and to obtain microbiological confirmation. Furthermore, surgical treatment should be combined with an 18-month course of anti-TB chemotherapy, during which period patient compliance should be closely monitored.

Objective Infratentorial empyema is an uncommon form of intracranial suppuration that is usually secondary to neglected otogenic infection. The diagnosis is frequently delayed and often confused with that of meningitis. The associated mortality is distressingly high, yet it has, as a clinical entity, received scant attention in the literature. We present a 13-year experience of this condition. Patients and methods From a retrospective analysis of 3865 patients with intracranial suppuration during a 13-year period, 22 patients with infratentorial empyema were identified. The inpatient notes for these patients were analyzed with reference to clinical, radiological, bacteriological, operative, and outcome data. Results Twenty-two patients with infratentorial empyema accounted for 0.6% of admissions caused by intracranial suppuration during the study period. Of these 22 empyemas, 13 were subdural and 9 epidural. Hydrocephalus was present in 17 (77.3%). Except for two epidural empyemas that did not warrant neurosurgical intervention, all patients underwent standard surgical management (wide posterior fossa craniectomy). Nineteen underwent mastoidectomy because the source of infection was otogenic. Concomitant and persistent hydrocephalus was treated aggressively. Five patients died (mortality rate of 22.7%). All fatalities had subdural empyemas, and all three patients with cerebellopontine angle extension of subdural purulent collections died. Conclusion Although rare, infratentorial empyema, especially when subdural, is a lethal disease. Cerebellopontine angle extension of pus was a particularly ominous sign in our experience. Early surgical drainage via wide posterior fossa craniectomy, aggressive treatment of associated hydrocephalus, eradication of the primary source of sepsis, and, finally, intravenous high dosage of appropriate antibiotics form the mainstay of treatment.

Objective Calcifying fibrous tumor is a rare, benign soft-tissue tumor of unknown etiology, characterized by hyalinized collagenous fibrous tissue with psammomatous or dystrophic calcification and focal lymphoplasmacytic infiltrate known to involve different organ systems. Involvement of the spine and the presence of metaplastic ossification previously have not been reported. Intervention We report a 44-year-old female with progressive nontraumatic flank pain. Imaging revealed a left-sided retroperitoneal calcified mass attached to L5 body with no evidence of extension into the neural foramina, nearby vascular structures, or psoas muscle. The patient had an en bloc resection of the tumor via the transabdominal approach. A pathologic diagnosis of calcifying fibrosis with metaplastic ossification of the spine was reported. Postoperative recovery was uneventful and there is no recurrence after 18 months of follow-up. Conclusion Calcifying fibrous tumor, a rare benign soft tissue tumor must be considered in the differential diagnosis of a retroperitoneal calcified mass closely associated with the spinal column. Spine surgeons should be aware of this rare pathologic disease entity and although its natural history is not clear, marginal excision is usually adequate.